Category Archives: physician

Reconnecting to Mission, Patients, and Colleagues

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What’s the most personally fulfilling aspect of your work?  In times of uncertainty, threat, and transition, what holds you up?

This past week, I had the privilege of standing alongside giants in the fight against physician burnout.  In a series of presentations at the annual meeting of the American College of Physicians (ACP), we did our best to acknowledge and validate the current state of physician burnout (about half of all physicians in all specialties report at least one symptom), and then present as many strategies to reduce it as time would allow.  We showed how changes in workflow, task distribution, and technology, such as pre-visit labs and scribes, have been shown to improve physician satisfaction, team morale, and patient experience.  My role was to attempt to inspire my fellow internists to claim their individual agency, model a culture of wellness, and advocate for systems change in their home institutions.

The content felt dense but manageable, and the audience appeared engaged.  Our colleagues from all around the country approached us afterward to clarify studies of efficacy and ask about local representatives for advocacy in the ACP.  In the end, I think we achieved our primary objective of having most attendees leave with just a little more hope for our profession than they came in with.

Over the four day conference, however, what consistently grounded me in professional mission and meaning, not only in our own presentation but in others, were the personal stories.  That is how we humans relate to one another, after all—through narratives.  And connecting to mission and colleagues is key to maintaining a healthy and productive workforce, physician or otherwise.

Our attendees participated in two practices that I’ll share here.  Both were “Pair and Share” activities, meant to stimulate reflection both internally and externally.

Who In Your Life Really Changed You?

First we asked our colleagues to think of a patient who changed them, how, and to what end.  I know there have been many patients who changed me, but I always think of one particular woman.  She was middle aged, obese, diabetic, depressed, and severely disabled from osteoarthritis.  She lived alone and had a sparse social network, and her life partner had died unexpectedly a few years before I met her.  At every visit we struggled through the same fundamental challenges of weight loss, glucose control, and pain management.  How could she take her diabetes medications more regularly?  How could we control her pain without having to take opioids every day?  How else could we manage her depression, as some of the medications were raising her blood sugar?  She may have cried at almost every visit; wailing was not uncommon, and once she even vomited from cumulative distress.  Our relationship was good overall.  I overcame my impatience with her non-adherence to the treatment plan as I understood her life situation better.  But for four of the five years we knew each other, I saw few if any indicators that her thought, emotional, and behavior patterns would change.

Then things started to turn around.  She started coming consistently to appointments, no more no-shows.  She got online and found a community center that was accessible by bus.  She connected with a knitting group and started going to art fairs to sell her creations.  She started taking her medications more regularly, and lost enough weight to have her knee replaced.  By the time we parted ways, she had transformed from a weeping victim of circumstance to a woman with agency, self-efficacy, and goals, dammit!  And most of this had nothing to do with me.  I simply had the privilege to witness and support her intrinsic revolution.  From her I learned what perseverance looks like; I learned about hope and self-redemption; I learned that I should never make assumptions about anybody’s future.

Who Supported You in a Time of Vulnerability?

They said do the hardest thing that you know you don’t want to do for a living as your first rotation.  So I chose surgery.  In July of my third year of medical school, my days started around 5:30am and could end the next night at 10pm if my team was busy post call.  Most faculty physicians were kind and wise, or at least non-abusive.  Some, however, not so much.  What buoyed me most through that rotation was always the support and protection of the residents on my team.  I would watch them get abused by our attendings, but that sh*t never rolled downhill when the boss left the room.  I did not fully realize until years later what a gift that was and how much it spoke to the character of these men (they were all men).  This was in the 1990s; verbal abuse of medical students and snide comments about one’s appearance, gender, and just about everything else were simply to be expected.  But my favorite residents always pulled me aside and asked how I was.  They always made sure I felt confident about my role on the team, and they taught me basic skills with conviction and encouragement.  As I was about to insert a patient’s bladder catheter in the operating room, my elder brother in training told me firmly, like he really believed I could do it, “Don’t be afraid, hold it (the penis) like a hose.”

As we did this reflection exercise at the meeting last Wednesday along with our audience, I was so moved by these memories that I looked up one of my old residents that night and sent him a thank you card.  I bet he won’t remember at all who I am, but he will hopefully feel validated that he is in exactly the right position now as program director of a surgery residency.

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Recalling stories like these, and then sharing them with a person who truly listens, receives them generously, and simply helps you hold them (that was the instruction to the group—when it’s your turn to listen just do that, no interruptions, no jumping in), reconnects us to our calling in medicine.  It’s not just about the patients or the science.  It’s about all of the relationships and how we tend them.

We will not solve the immensely complex problem of physician burnout overnight.  It will take a concerted effort at all levels of healthcare, and physicians cannot and will not do it alone.  And it’s not that we are stoic, arrogant, and somehow intrinsically flawed, and thus dissatisfied with our work and leaving the profession in record numbers.  It is a systems problem, no question.  And, while we call our congressional leaders and professional advocacy groups to change policy, while we lobby our hospital administration to hire more support staff and move the printers closer to where we do our work, we can all take a few minutes each day and reconnect to the core meaning and purpose in that work.  Let us all remember a cool story and share it today.

Pain and Desperation

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When was the last time you used any narcotics?  I think I took some of my mom’s cough syrup with codeine over a decade ago, when I felt like I might actually cough up a lung.  Before that it was one dose of Darvocet after having four impacted wisdom teeth extracted at age 18.  I don’t really remember much after swallowing the pill and lying down on the sofa.  I was given multiple opioids during knee surgery last year, but needed only Tylenol and Advil afterward.  Looking back on the post I wrote about that experience, I realize even more how I was influenced by this piece in the New York Times just a month before my surgery.  In it the author is reminded that pain serves an essential purpose, and it’s better that we not necessarily seek to obliterate it at every turn.

* * * * *

Four or five times in the last two weeks, I have received calls from local pharmacies to confirm opioid prescriptions that I did not write.  They were all paper prescriptions for patients I have never met, caught by astute pharmacists who suspected fraudulent activity.  This is the first time it has happened to me, and I know many of my colleagues have experienced the same.  Pharmacies in the area have now flagged my name and license number, and they know not to fill any controlled substances without direct confirmation from me.

What a morass.  How did we get here?  It’s a rhetorical question, really, but not a simple one by a light year.  When I started my training, we were taught to consider pain the ‘5th vital sign.’  Every patient assessment included the cartoon face pain scale.  Anesthesiologists’ prioritized rubrick for pain control started with long acting opioids around the clock, then regular anti-inflammatories if no contraindications, then short acting opioids as needed for breakthrough pain.  In the hospital I never questioned this method, especially since I almost never interacted with these patients after discharge and was oblivious to follow up issues.

It was not until I started in practice that I experienced the multidimensional challenge that is pain control and opioid prescribing.  After 15 years I am still learning the layers of complexity, unique for every patient, and I see that even if we understand it (which I think we do not), most of us feel helpless to address it.

The pharmacist I spoke to today told me that his store’s standard procedure is to inform the patient that the prescription was proven to be fake, advise the patient not to attempt such an act again, and let them know that the prescriber is aware and the police will be contacted.  It was that last part that made me pause.  Because even as I intend to file a police report (as advised by my institution), the answer to the problem is not, in my opinion, rounding up patients with chronic pain and throwing them in jail.  In order of importance, I think the opioid crisis is first a social, then a medical, and only then, a criminal problem.

* * * * *

Increasingly, we have become a society of immediate gratification and entitlement.  We want and expect a magic pill for and complete relief from whatever ails us—because it’s the twenty-first century for crying out loud, how could we not have that already?  Also, medicine has become increasingly transactional.  We, patients and physicians alike, experience ‘care’ in predetermined packets of protocol and procedure, and spend considerably less time in conversation, education, expectation setting, and actual caring.  The advent of the internet has accelerated this immediate gratification expectation.  It also gives many of us an illusion of connection through social media, when in reality, we are actually less and less connected to one another.

Pain results from myriad causes.  We all have varying thresholds for feeling and tolerating pain, which vary themselves depending on circumstances, mindset, expectation, and meaning making (think childbirth versus bike accident).  There are so many factors that impact our pain experience, including dehydration, sleep deprivation, low mood, and emotional and/or mental stress.  Loneliness, depression, anxiety, sleep disruption, suicidality, and substance abuse are all on the rise.  And all of these conditions lower our thresholds for pain and the harm it does to us.

For many, opioids are indeed the immediately gratifying magic pills.  But the magic wears off faster and faster, and both pain and the desperation for relief accelerate in the wake of short and long term withdrawl.  As physicians, we feel an intense desire to alleviate suffering.  Once a patient has experienced the profound relief (both physical and psychological) from opioids, it feels cruel for us to withhold them, even when we understand fully their risks and the long term harm they cause.  And we have less and less time to explore with and educate patients about adjunct pain management practices, such as mindfulness, biofeedback, and movement.  Everybody feels despairing and impotent, and this drives people to do things they might not otherwise do, like make a fake prescription for hydrocodone and try to get it filled.

I know there are real criminals out there, people not really in pain, who do this to make money—to take advantage of people in real pain.  I don’t know who’s who.  But the story I tell myself is that this is not most people.  What we need is a stronger infrastructure to address chronic pain at multiple levels—individually, in community, with policy, and culturally.  As I write this, even as a physician with a leadership title, I feel powerless and a little hopeless.

But maybe a good start, at the individual level, that we can each do the next time we look ourselves in the mirror or meet another human being on the street, is to just exercise a little compassion and generosity.  I assume that those patients presenting the fake prescriptions, if they are real patients, are not criminals at their core.  Pain makes us do unthinkable and unbelievable things.  I hope we can all help one another find better sources of relief and support.

Theory and Practice

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Does anyone become a great skier or volleyball player by just reading books and watching videos of other people doing it?  Of course, not.  And even if you have the best coach, with the most knowledge and expertise, you still have to get out on the trail or the court and do it yourself, find your own groove, create your own style and habits that work for you and your team.

I realized this over the past week, as once again I found myself calling forth everything I have learned about leadership from books and observations of other leaders.  Leading people is hard, and I often feel at the same time that I do it well and that I totally suck at it.  I worry that because it feels mentally and emotionally exhausting, I must be doing it wrong—like if I really knew what I was doing it would just be easy.  But that is perfectionism and fixed mindset talking, I’m pretty sure.

Knowing theory is key, no question.  If you don’t understand in advance what it will be like to stand up on skis (they don’t stop themselves and if the tips are pointed downhill that is exactly where you will slide), you will fall and risk injury to self and others a lot more than if you are prepared with a few pointers in advance.  It’s the same with leadership.  Remembering how it feels to be led well, versus poorly, allows me to have empathy for those I lead.  Mastery of, or at least proficiency in, some key communication tools such as reflective listening, nonjudgmental questioning, and objective feedback, makes the skills easier to access under stress and pressure.  Holding core values and principles in front, and exemplifying them, rather than just professing them, earns trust and credibility.

I wrote to a mentor recently, “I find myself repeating language from the books, inventing analogies and using examples from the team’s lived experience to show how the theories apply.  Words like empathy, curiosity, generosity, non-judgment, deep breathing, and ‘How fascinating!’ exit my mouth a lot, as well as, ‘It’s all about relationships!’ People must see me as a broken record…”  He reminded me that we need these mantras to keep ourselves focused and also to repeat out loud and invite accountability in our actions.  I wholeheartedly agree.  Maybe I will take a misstep here or there (no maybe—it will happen!).  It won’t be because I’m not trying or I don’t care—it will be because I’m human and we all make mistakes.  It’s because I’m out there practicing.

When I think back to high school volleyball practice, residency, personal training, and the early days of parenting (hell, every day of parenting), it’s not the easy days that stand out in memory.  It’s the hard days, the days when I really struggled, but came out having grown, even in a little, in my learning.  It’s the days when I can say, hey, I know better now, and I will do better next time—bring it.

So yes, leading well is hard.  It’s exhausting.  It costs inordinate amounts of energy, self-awareness, -monitoring, and -control.  It makes me hypervigilant of my words, posture, and actions.  Theory and practice go hand in hand; they are the twin pillars of learning, application, and success in all realms.  I will keep reading for theory (I highly recommend Legacy by James Kerr and Big Potential by Shawn Achor).  I will keep showing up every day ready to do my best in practice.  I feel confident in the trust and credibility I have already earned, and that people can see that I’m honestly doing my best, for all of us.