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.

Why I Cried On Rounds

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Wow friends, I’m inspired.  You know that’s the case because I sit here less than 24 hours after my last post, writing again.

Today I learned about Public Narrative during the ICCH conference workshop entitled, “How to Become an Effective Advocate for Humanism in Your Healthcare Organization”.  The process was developed by Marshall Ganz, at Harvard.  Here is the course description (MLD-355M Public Narrative: Self, Us, Now):

Questions of what I am called to do, what is my community called to do, and what we are called to do now are at least as old as the three questions posed by the first century Jerusalem sage, Rabbi Hillel:

If I am not for myself, who will be for me?

When I am for myself alone, what am I?

if not now, when?

This course offers students an opportunity to develop their capacity to lead by asking themselves these questions at a time in their lives when it really matters. . . and learning how to ask them of others. Public narrative is the leadership practice of translating values into action. To lead is to accept responsibility for enabling others to achieve shared purpose in the face of uncertainty. Public narrative is a discursive process through which individuals, communities, and nations learn to make choices, construct identity, and inspire action. Responding to challenges with agency requires courage that is grounded in our capacity to access hope over fear; empathy over alienation; and self-worth over self-doubt. We can use public narrative to link our own calling to that of our community to a call to action. It is learning how to tell a story of self, a story of us, and a story of now. Because it engages the “head” and the “heart” narrative can instruct and inspire – teaching us not only why we should act, but moving us to act. Based on a pedagogy of reflective practice, this course offers students the opportunity to work in groups to learn to tell their own public narrative.

See also this video, where Ganz describes the central tenets himself.

In our introductory workshop today, we were invited to try writing our own narrative, and provide/receive feedback from a fellow participant.  My responses to the exercise prompts are below.  Just want to share.

  1. What is the change you want to make in the world:  Your Story of Now?

I wish to improve all of our relationships:  To foster meaningful personal connections in all realms, in an increasingly disconnected (yet deceptively ‘connected’) world.  This includes doctor-patient, doctor-administration, parent-child, teacher-learner, political opponent, colleague, friend, spouse relationships and more.  We all desperately need deep connection now more than ever.

  1. Why are you called to make this change: What specific experiences have shaped your Story of Self?

I am a Boundary Spanner.  From early in life I have repeatedly and consistently found myself in Middle Spaces, serving as liaison between divergent perspectives, such as family members, Chinese and American culture, conventional and alternative medicine, patients and physicians, physicians and our leaders.  I have an easy ability to take perspectives, withhold judgment, and communicate to connect.  I am perfectly positioned to do this work—I live at the intersection of each of these relationships and others, and I am comfortable serving as a bridge.

  1. What personal story can you tell that will help others understand why you want to make that change? What is the challenge?  The choice?  The Outcome?

In my fourth year of medical school, I rotated on nephrology consults.  Hospital care teams called us to evaluate their patients who had new kidney failure in the hospital, to advise on potential causes and make recommendations for treatment.  I had become confident in my knowledge in renal pathophysiology and collegial communication skills.  On this day we were consulted on a patient in the intensive care unit.  I was taken aback when I saw the man—a Vietnamese man close to my dad’s age.  He was gravely ill, intubated, swollen and jaundiced.  I met his daughter, who looked about my age.  Her hair was jet black and straight, cut like a schoolgirl’s.  She wore a modest t-shirt tucked into high-waisted jeans that looked about a decade behind the current fashion trends.  She did not speak English, so our encounter was brief.  But I remember being struck by the utter confusion and fear in her countenance.  She looked like a deer in the headlights.

I conducted the usual chart review, lab analysis, and physical exam.  I thought through the usual causes of acute kidney failure in critically ill patients, and then the concurrent conditions that made treatment a fine balance of volume, pressure, and perfusion (sepsis, heart failure, kidney failure).  But this case, though medically typical, was emotionally fraught for me.  I saw my own family in this patient and his daughter.  What if my dad had fallen critically ill when he arrived in the US back in the 1970s?  Who could have advocated for him, and how could his care team know what they needed in order to care well for him?  My heart went out to this man, likely about do die, and his daughter, apparently alone to manage everything for him and herself.  I related in a way that surprised and scared me, and I felt vaguely uncomfortable.

So when I overheard the ICU and nephrology consult residents making offhand fun of his monosyllabic last name, as so many people had done to my name growing up, I lost it.  I started crying right there in the unit, or maybe when our team rounded, I don’t remember.  I felt embarrassed and also angry.  How unfair.  These residents had not even known what they had done, they had no idea that I reacted to their words and attitude, which I imagine they would have defended as benign.  I was too embarrassed to say why I was so upset—felt it was selfish, unimportant.  I worried they would think I was being hypersensitive, over-reactive.  I also worried, I realize now, that I would hurt their feelings if I told them how much their passing, offhand remarks had hurt me.  It was too much, and I could not voice any of it.

So my team, perplexed and taken by surprise even more than I, just sat.  They were confused, concerned; they did not know what to do, had no skills at their fingertips to make it safe for me to open up and share.  I don’t remember any gestures of support or reassuring touch.  They sat, like deer in headlights.

My choice was to speak up or not.  To bring attention to what might today, I suppose, be labelled a microaggression?  I chose not to speak.  The outcome is that I regret.  I regret that nobody had any way of consoling me, even as they did not know what was happening.  I regret that I did not have the courage or language to describe my experience, that I did not advocate for myself and future Asian immigrant patients.  I liked our attending.  He was a decent and caring man.  But he had no idea what to do.  If he had briefly halted rounds and taken me aside privately, or asked to sit down later, I might have shared my story then.  But he did not.  I pulled myself together, we completed rounds, and nobody ever brought it up again that I remember, myself included.  He wrote a very generous letter of recommendation for me for residency.

My challenge today was to make sense of this sudden and profound emotional hijack, after marveling briefly that this was the only story that emerged to tell.  I had not thought about this incident in many years already.  My pair/share workshop partner pointed out, insightfully, that once again I found myself in the Middle Space, spanning the boundary between the modern American healthcare system and an East Asian immigrant family unit, both personally familiar to me, and mutually unintelligible to the people on either side.  “I’m not surprised that you’re trying to do something with this story,” she said.  Yes.  My calling is to foster awareness, respect, and mutual understanding between all people.

This is why I get Hippie Zealot Conference High, because insights like this hit me every time I commune with my meeting tribes.  Can’t wait to see what happens tomorrow.

Medicine:  Science + Humanity = Professional Pride

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Lots of learning this month, friends.  I’m overwhelmed and overjoyed, and proud of my profession.

It’s too much to write about in one post, but I will try all the same, in order of occurrence.

18 October 2019

Once again I had the privilege of meeting with medical students, this time to discuss their experience of leadership in medicine.  As is my new custom, I started with an appreciative inquiry exercise: What is the best thing about medicine, WHY do you do this?  One of their responses:

“The medical encounter is a unique combination of compassion and intellect—the conversation is my favorite thing, and that I also get to help.”

19 October 2019

Looking through the basement bookshelf, I came across my medical school application from 1994.  The general application included a one page personal statement, in which I wrote:

“Science, and the human body in particular, have always fascinated me… In practice, while I pursue the challenge of each new patient’s illness, I want to share with them my enthusiasm for the science of medicine…  But being a doctor involves more than curing people’s illnesses…  It is the job of the physician to reassure and comfort the patient…  In my practice I will…do my best to communicate with (patients) in terms they will accept.  The best way to comfort people is to relate to them.  I believe this skill will make me understand not only patients’ medical needs, but their emotional and psychological needs as well…  I hope to keep learning from my patients in the future.”

Turns out I’ve been both a science nerd, and also thinking and writing about relationships and connection for a while now, go figure.

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25-26 October 2019

This year’s ACP Illinois Chapter Meeting was the best one in recent years, in my humble opinion.  I’m so proud that under the leadership of our Northern Region Governer, Dr. Suja Mathew, we were able to present a robust clinical education conference, as is the ACP tradition.  Along with sessions on diabetes, heart failure, office orthopaedics, and cancer survivorship, however, we also included sessions on critical social and public health issues, such as diversity/inclusion, the impact of social media, firearm injury and death, medical marijuana, trauma-informed care, and sexual harassment in the workplace.  Esteemed colleagues from across the country came to share their expertise.  Here are just a few examples of Science + Humanity, in action every day in our work:

Diabetes

Science:  We now understand that it’s the wide swings in blood sugar, and especially very low sugar, that lead to end organ damage.  We have new classes of drugs with novel mechanisms of action.  They decrease the burden of glucose control on pancreas cells, and also seem to prevent heart failure in some patients.  Humanity:  All diabetic patients need education—face to face time with a trained professional who can teach them about the disease and how to manage it. Even the most highly educated and most well-informed person cannot automatically know how to be a diabetes patient without the help of these medical team members.  More and more, diabetes care in particular is a team sport, and our collective skills get better every year.

Cancer

Science: We are curing cancer.  There are more survivors now than ever before, thanks to targeted genetic and immunotherapy and minimally invasive surgery, among other treatments.  Humanity:  Survivorship starts at the time of diagnosis, and cancer patients have both unique and diverse needs and concerns.  Complications from treatment such as neuropathy and heart failure can occur years out from treatment, and the psychosocial consequences for patients and their families can be lasting and transformative.  The better we understand this as their care teams, the healthier and happier our patients will be.

Childhood Trauma

Science: Since the 1970s, cumulative evidence shows that Adverse Childhood Experiences and trauma correlate with an increased risk of negative health behaviors, mental illness, chronic diseases such as diabetes and heart disease, decreased academic performance, limited professional productivity, and early death.  And they appear to affect each of these outcomes independently.  In the Tree of ACEs, branches and leaves represent the interpersonal experiences.  We are only starting to understand the roles played by Adverse Collective Historical Events (slavery, genocide, mass incarceration, forced displacements)—the soil, and Adverse Community Environments (poverty, violence)—the roots.  HumanityThe key factor that correlates with escape from the early mortality path from ACEs is a stable and nurturing relationship with an adult caregiver.  As healthcare providers, we have a unique and important part to play in the healing of all ACEs—our patients’ and our own—and all evidence points to the quality of our patient-provider relationships as foundation—no surprise.

Gun Violence

Science: In 2012 33,000 people died from firearm injuries (it was up to 40,000 in 2018); 62% of these deaths were suicides.  That same year there were 62,000 nonfatal firearm injuries, 72% of which were assault, 5% self-inflicted, and 17% unintentional.  Higher rates of gun ownership correlate with higher rates of death from firearm injuries.  States with both background checks and waiting periods have lower rates of suicide by firearm compared to those with background checks only.  It is still unclear whether states with more lax concealed carry laws have different rates of firearm related deaths compared to stricter states.  Humanity: Though mass shootings dominate the media, the majority of deaths from firearms are self-inflicted.  The acute impulsivity of mental illness, combined with an accessible, loaded firearm, destroys lives—whole families and communities at a time.  Our job as physician advocates is to not alienate gun owners, and rather enroll and recruit their help to address the factors that take our friends and loved ones from us.  It’s not an Us vs. Them fight over rights.  It’s a shared challenge to create policy that honors our unique national history and culture, and also effectively addresses our public health crises.  Here is where our highest notions of collaboration, respect, and shared purpose must be exercised.

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27-30 October 2019

Today I arrived in San Diego for the International Conference on Communication in Healthcare, my first time at this meeting.  Many of the sessions will present research on effective ways to teach communication skills to trainees, factors that impact health literacy, and methods for measuring effective communication.  This conference is all about the science of communication in healthcare.  And it’s also about the humanity.  The first plenary speaker was Dr. Lisa Fitzpatrick, who interviews people on the streets of DC in her series, “Dr. Lisa on the Street.”  The videos show over an over how people feel ignored and dismissed by our healthcare system, and how unsafe it is for them to admit what they don’t know or ask questions.  This is one of the only meetings I have attended at which patients are invited to present and voice their perspective.  At the end of this session one patient attendee stood up and spoke words that will guide me throughout this week and my career:  “Doctors may have all the education in the world, and if you cannot talk to your patients in a way that makes them trust you, it really doesn’t matter.”

Sessions I plan to attend:

Moving Health Care from a Team of Experts to an Expert Team

How to Become an Effective Advocate for Humanism in Your Healthcare Organization

Collaboration and Communication Across Multidisciplinary Healthcare Teams

Civility Ninjas:  A Field Guide to Improving Colleague-Colleague Interactions

Understanding and Addressing Mistrust

Shared Decision-Making as Ethical Practice

Thanks for reading to the end, friends.  I know it was a lot.  As I age I learn to hold patience as well as eagerness, absorbing the input as well as creating my own, integrated outputs for good.  How lucky I am to have so many amazing people to keep me company on the journey!

Four days to NaBloPoMo, my fifth attempt, HOLY COW!  Better get to bed…