Dr. Jerkface In Context—Healing the Patient-Physician Relationship

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Excuse me, I took an unintended break for Thanksgiving!  Hope you all had a wonderful holiday!

NaBloPoMo 2017: Field Notes from a Life in Medicine

For the past year or so, maybe more, I have increasingly tried to engage my friends in discussion around allied advocacy for physician health and well-being.  Inevitably, however, I’m met with anecdotes from my friends about asshole doctors.  It is a strikingly common experience, I’m sad to report.  And it makes sense:  If a patient has a bad experience with a doctor, ie the doctor behaves badly or the patient feels dismissed, ignored, disrespected, or mistreated, the normal response is to blame the doctor and assume that s/he is an asshole.  In each of these interviews with friends, it took a while for them to come around to the idea that the doctor him/herself may be suffering and therefore not behaving/performing their best.

But the next question is this: Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.

Right now I see it as a very personal, grassroots endeavor.  Outside of a one-on-one patient-physician relationship, ‘patients’ and ‘physicians’ in general are abstract groups to us all, and it’s hard to feel compassion for and connection with an abstraction.  “Patients are too demanding, entitled, and ignorant.”  “Doctors are arrogant, dismissive, and profit-driven.”  We carry these overgeneralized internal narratives and others into our encounters, often unknowingly and unintentionally.  Even when we think we see and know the person right in front of us, these underlying assumptions still color our experiences with them.  So whatever conversations we may undertake will take many repetitions to finally reach true mutual understanding.

I have been a member of my church since 1991.  Many others in the community have been there much longer than that.  There are other physicians, and we are all patients, ranging in age from infants to octogenarians.  I have proposed to host a focus group to discuss patient-physician relationship, especially as it relates to the effects of physician burnout on patient care.  The plan is to do it once, with whomever is interested, and see what happens after that.  I picture 10-20 people, patients and physicians alike, seated in a circle.

The objectives will be stated:

  1. Hold an open discussion about people’s experiences in the patient-physician encounter, and explore the context of forces that influence those experiences. Such forces include visit duration, documentation requirements, workflow inefficiencies, patient expectations, insurance status, and clinical setting (hospital, outpatient clinic, etc.).
  2. Participants leave with improved mutual understanding of one another’s experiences in the medical system and more likely to feel empathy and compassion toward their counterparts in the next encounter.

In the long term, I wish for patients and physicians to form a unified platform from which to advocate for policy change.  We, patients and physicians, are the end-users of the healthcare system, the largest combined demographic in the system, and I believe we are the ones who benefit the least from the system.  Health outcomes for American patients are dismal compared other developed countries, despite our exorbitant expernditures.  Physicians kill ourselves at more than twice the rate of the general population.

It’s not enough for medical professional societies to write co-authored, open letters to Congress.  It’s not enough for individual patient constituents to stand up at town halls and berate their representatives.  We must orient ourselves as resistors in series, rather than in parallel.  I think the movement will grow most effectively out of existing connections and relationships, through which we can find shared interests, common goals, and a strong, unified voice for change.

I seek your feedback:

  1. How do you picture this meeting going?
  2. How interested are you in learning about physician burnout and how it affects patients?
  3. If you were invited to such a meeting, what would you think and feel about it?
  4. What would make you more likely to participate?
  5. Would you want to host such a meeting in your community? How would you do it?

Thank you for considering, and see you tomorrow!

I’m the Doctor, You’re the Doctor

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NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.

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

Exploring the Rules of Engagement: A New Blog Series

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The Descent and the Rising

The past two weeks have assailed, masticated, consumed, digested, and expelled important parts of my psyche.  A week after basking in peaceful solidarity at the Women’s March, I found myself losing sleep and breaking out—both signs of acute distress.  My mind swam with questions of identity, purpose, and action.  I wrestled with fears around policy, violence, and integrity.  All of a sudden I wasn’t enough, I wasn’t doing enough.  Resist!  Call your representatives now!  Support this march and that protest!  And on the internet, rage escalated everywhere.

I read this article, which I highly recommend, on how to stay engaged and not lose your mind.  The author recommends that we focus our actions on one or two issues, and gives useful self-care tips.  After a few days, I was surprised to find that no particular issue moved me enough to passionate advocacy.  I began questioning my dedication.  But thank God for therapy (which the author also recommends), hallelujah!  I had a breakthrough in session last week, wherein I realized that I am, actually, enough.  And I do actually affirm one key interest: Relationship.

Duh.

For me, it’s less about specific issues than it is about how they’re addressed.  While generally I favor a progressive social agenda, I abhor the entrenched, partisan, winner-takes-all attitude that infects our government operations and civic discourse.  I also deplore the rhetorical, broad brush generalizations that people make about one another, based only on how we voted or an oversimplified position on one issue.  I wrote about this recently, though I buried the thesis in what should have been a separate discussion of healthcare reform.

Looking back, of course, relationship and communication have always been my core concerns—I launched this blog specifically to discuss them, for crying out loud!  Over and again I find myself in the role of mediator—between family members, Chinese and American culture, conventional versus alternative medicine, and between patients, physicians, and the healthcare system.  My whole life I have practiced, sometimes under duress, the art of mutual understanding and negotiation.  Maybe I’ve just been training for this moment in history.

How Talking Politics Is Like Eating Healthy

We could all learn and apply better practices.  We know the theories—more vegetables, less judgment, whole grains instead of processed, less name-calling and more calm, reasoned debate.  But so often the opposite happens:  junk food, sugary sodas,  pointless shouting and blaming—especially on social media.  We feel ashamed and frustrated at the futility of it all.  We figure screw it, I’ll never change (and neither will they), so why bother, it’s too much work, and anyway, it’s not the end of the world.

Never mind that your rising blood pressure and glucose accelerate the formation of atherosclerotic plaque each passing year, and that your risk of dying from a heart attack or stroke escalates exponentially as a result.  Never mind that the less we engage one another in meaningful ways, the farther apart we drift and the more we allow the most extreme factions of our parties to run the show.

The Challenge

In the coming weeks, I will share my own key learnings on healthier engagement practices.  I make no claims to have all the solutions, and I do not mean to be preachy.  These posts will serve mainly as reminders to myself, aspirational pieces to hold my own feet to the fire, marshaling my highest ideals of thought and behavior.  I will try to minimize promoting my own political views, though I suspect they will surface one way or another.  I hope you will follow with an open mind, and a heart that yearns to connect with the best of humanity, especially in those with whom you may disagree.

I’ve said it before and I’ll say it again:  It’s our relationships that save us.  Right now they desperately need repairs.  So let’s get to work.

Inaugural Intentions

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Things are feeling a bit dark again…  Reminds me of October, when I got emotionally hijacked by current events and found myself anxious and angry, but wouldn’t admit it for a while.  On the eve of a new presidential administration taking office, tensions run high once again and I’m challenged to avoid a similar decent into despair.

It really helped to take the Holiday Break and write to my friends.  I did it by hand, with colorful pens, stickers, and rubber stamps (I love rubber stamping).  I intended to connect more personally, and that’s exactly what it felt like.  As I see and hear expressions of fright, dread, sadness, anger, and pessimism among them, I intend to continue corresponding by pen and paper.  There’s just something more tangible about it, more intimate and permanent than email, text, or Facebook.  I have included excerpts below—the ones that felt particularly inspired.  They represent my intentions for managing myself in the coming years, of reinforcing my core values and focusing on my highest aspirations.  As Simon Sinek posted once:  “Fight against something, we focus on what we hate.  Fight for something, we focus on what we love.”

To my friends who have expressed, “get over it,” and “stop whining,” I respectfully request that you try to empathize with those of us who feel despondent.  Nothing will improve if we keep ridiculing and belittling one another.  If you experienced this from ‘us’ before the election, remember how it felt.  Rise above our worst collective behavior and help us overcome our fears and disappointment by showing us that we really do share more love and connection than we might think.

Unity and true indivisibility require all of us to pitch in and reach out.  I hope that by one year from now, we can all look back and feel proud of the connections and relationships we strengthened, from left to right and otherwise.

***

What a crazy year…  All bets are off, no one can possibly predict what will happen now—so much anxious uncertainty surrounds us all over the place!  …And yet I feel hopeful and optimistic.  This is the time for our best selves to truly shine—the perfect opportunity to call on everything we have trained for—all of the grit, the kindness, the curiosity, the openness, the brave vulnerability~~~all of it, in service of connection, mutual understanding, and forging a way forward to a BRIGHTER future!  Because we now know, again, in humanity’s history, what darkness looks and feels like.  We can’t stay here, and we won’t—we can each shine a light.  And if we stand close, the light amplifies exponentially.

So thanks for being a fellow light shiner, (my friend)!  May we keep our connections with each other and our other fellows ever close—we need us—the world needs us—now more than ever!!  Keep it lit, my friend.

***

…Hope this card finds you well and HOPEFUL.

Because I have decided that that is what we all need to practice more now than ever—HOPE.  Those of use who strive for conscious living and more connection than the superficial have TRAINED for this moment in history—to PRACTICE OUT LOUD and IN FRONT of everybody—to lead by example and make the difference we were born to make!  We don’t need to do big things—we just need to keep the faith and stay the course!

’Small things with great love,’ I think Mother Theresa said?

Please know I am here to support your efforts, as I know you are for mine!  Let’s get together and hold each other up again soon!

***

…Because I know so many people whose core values represent the BEST of our shared humanity—equality, compassion, community, connection, love, and forgiveness.  The world needs these qualities and practices by us more now than ever—so if we hold each other up, we’ll all be able to do the work better—TOGETHER!!  So here’s to long friendships and deep love!

***

I received this handwritten response from an old friend today.  It warms my heart and holds up my hope:

“While we may snarl a bit at anticipated political shenanigans, let us remember we have strength in numbers and determination to keep life in this country respectful and fair—simply by the ways we live and interact.”

***

And finally, I’m also encouraged that our international leaders express a similar optimism:

Angela Merkel: “I am very much convinced that we as partners benefit more if we act together than if everyone solves problems for themselves, and that is a constant fundamental attitude on my part.”

Peace to all of you, dear friends.  Let us manifest our best every day.

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 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!