Happy New Year! The Pause To Reflect

“Every new beginning comes from some other beginning’s end..” – Closing Time, Semisonic

Sunset, December 2014, Falmouth, MA looking towards Martha’s Vineyard

We come end of 2014, and to New Years’s Eve, the annual celebration of flipping the page to the next calendar year. This celebration has always seemed a little forced, a little arbitrary (especially as there are other calendars out there celebrating other new years). My brother, back when he was bartending his way through school, used to refer to it as one of the amateur nights. I enjoyed the parties, especially when I was younger and it was a chance for the old gang to reunite over the winter break.  As I have gotten older and friends have dispersed along their lives’ paths, I have preferred a quieter evening among family or close friends, if I am not working (and often I am). Some years I haven’t made it to midnight.

New Year’s Eve and New Year’s Day cap off the holiday season, and the completion of the calendar year. The last blast as we head in to the rest of a long winter, which has barely gotten under way, just past the solstice. It is a busy, hectic whirlwind time of year, full of lights and celebrations and family and friends and stress. Good stress and bad stress, but stresses all the same. It is also a time to reflect, take inventory. I think it is a good time to pause, and be still. Even if it is a brief island of peace in the sea of frenetic buzz and hubbub all around.

So as this holiday season and the year draw to a close, I am taking a moment of quiet, a deep breath, a pause, to be still. I invite you to do the same.

I reflect on this year as it comes to a close, and acknowledge the blessings and the people around me, who support me with their love, their affection, their friendship, their guidance. I can look back on the year just ending, its triumphs, its challenges, even its failures, with gratitude for the lessons learned from them all. Looking forward with hope and optimism, waiting to see what unfolds as I move into the new year. I know there are more challenges awaiting me; I must have faith that there will be successes, too, keeping eyes and heart and mind all open so that I recognize those opportunities as they present themselves.

Thank you for joining me on this journey Behind the Mask, as we continue forward together. Wishing health and happiness to all in the New Year!

Working Christmas: On ‘Being Essential’, Together

Do they know it’s Christmastime at all? – Band Aid


Snowy Wreath

Snowy Wreath

This is for all of the doctors and nurses. For all of the police and firefighters, EMTs and paramedics. P.A.s and N.P.s, techs and aides. You know what I’m talking about.

We are the “essential personnel”, the ones whose work includes nights and weekends and holidays. The ones who go out in the storms, even when everyone else stays home. “Stay off of the streets, except for essential personnel.” Schools close, businesses and banks and government close. Hell, even Dunkin’ Donuts and 7-Eleven close. But no closures or cancellations for “essential personnel.”

We essential types work lots of holidays. Correction, all holidays. Our friends and families miss us, learning over time to make the adjustments and accommodations for the holiday schedules. We hope they understand. If we are all very lucky, we can sneak in an early or late celebration. We sometimes miss it all completely. I think our families get a raw deal out of this; they don’t have the work responsibility to justify the interruptions and cancellations. They sacrifice, too, maybe more.

When Christmas and the holiday season come to the hospital, the atmosphere is festive. Continue reading

Context is Everything: Communicating Meaning in Medicine

“I do not think that word means what you think it means.” -Inigo Montoya, “The Princess Bride”

“Stick to Facts, sir! … In this life, we want nothing but Facts, sir: nothing but Facts!” Charles Dickens, Hard Times


Snowy shrubs, Massachusetts Winter

“Information without context isn’t transparency” flashed across my Twitter feed. So now I am thinking about context, and communicating context, in medical care.

This quote, from Heather Pierce, JD, MPH, Director of Science Policy and Regulatory Counsel for the Association of American Medical Colleges, was made in the context of a discussion of  The Sunshine Act. The Sunshine Act refers to the law and regulation mandating public disclosure of financial payments from for-profit companies to physicians. These payments are published without context regarding the relationship of the physician to the company or industry, if there is conflict-of-interest, or if they exert any influence. Payments or items/services valued above $50 are all included, to my understanding. They may be for a textbook, lunch for the office, a junket or meeting, or research. None of this context is specified.

The concept of information without context is itself extraordinarily important, aside from the controversy and opinions swirling around the Sunshine Act. Transparency is the buzzword in many aspects of life these days, from politics and policy, to commerce, to medicine. I will focus on some aspects of context in medicine.

It is ironic, then, that I am taking a quote about context out of context, to write about the importance of context.

 There are to me two main areas in medical care where context is important, and both are contained in the exchange between patient and physician. There is the context the patient provides to us, and there is the context we physicians provide back to the patient. All of this context depends on communication.

 The communication from patient to physician is crucial, even critical, in sorting out the details of symptoms and complaints. This history provides the context and framework for appropriate testing, and accurate diagnosis. Too often too many forces work against revealing this context. Time constraints on the patient visit, the crush and chaos of an emergency setting, the limitations of documentation (especially electronic) stripping nuance and detail from the record. Without context, the testing (labs, imaging) are no longer accurately aimed like a bullet, but becomes instead a shotgun blast, a scattered approach. The patient needs the time and space, and our interest and attention, to understand this context.

 Likewise, physicians provide context back to the patients. The context for the tests and results, the diagnosis, what it means. The meaning as it stands alone, and as it fits in the patient’s own context, which we mirror back to them. The transparency of sharing results with patients is important, but here, too, the context is important. Stakes are too high, miscommunication too easy a trap, misunderstanding and denial too common. Lab test, x-ray report, biopsy result all need to be communicated with attention to context. They are not stand-alone, black and white. It is my role as physician to help the patient understand, help formulate a plan, and that also means providing an interpretation (context again) for the results, helping the pieces of the puzzle fall together.

I am therefore not a fan of systems, whether laboratory reports or radiology results, providing results directly to patients, bypassing the ordering physician. The Skeptical Scalpel outlines the issue well, as he ponders, “Should radiologists tell patients their test results?” It is like the whole direct-to-consumer advertising mentality. And again, I believe it  all boils down to context. If we need to expedite getting the results to patients, then improve the communication between providers, between specialists, between departments. Permit the context to be shared and clarified in this space, too. Modify, alter, fix the system so that it facilitates rather than hinders these communications; transform the system so that it permits a place and space for the timely communication back to patients with room for context, and plan.

This is the space where healing and compassion dwell, where trust is built, where the bond between physician and patient is forged. There are too many forces inserting themselves into this space, where they do not belong. This is the space where meaningful and open communication happens. Where the patient and the physician become the team, not opponents. This is context. Most importantly, this is transparency. Isn’t this what we were after all along?

The Fragile Surgeon: A Fear for the Heart of the Profession

“You are human and fallible.” -Charlotte Bronte, Jane Eyre

“Alas, the frailty is to blame, not me – for such as we are made of, such we be…” -William Shakespeare, Twelfth Night

“Sha-doo-bee, Shattered…” -Mick Jagger, “Shattered”, The Rolling Stones, Some Girls (1978)

"Heirloom", deconstructed/cut china - Elizabeth Alexander, artist

“Heirloom”, cut china,                artist, Elizabeth Alexander

It seems incongruent, an oxymoron, even slightly disloyal, to refer to surgeons as fragile. Preposterous.

The Image of the Surgeon is synonymous with strength. Surgeons are stereotypically charismatic, commanding, confident, even arrogant. Strong minds, strong bodies, strong wills. Leaders, especially in the operating room; they even act that way in other healthcare teams and committees, even if it is not their official role. Surgeons endure long hours, grueling surgeries, all in addition to full office and clinic loads, and inpatient hospital census numbers on par with their non-surgical colleagues. It is intellectually, physically, and emotionally challenging work. Surgeons seem to relish it, thrive on it.

This is exactly why surgeons are so fragile. All of them.

I had an epiphany at the end my 4th year of medical school, when we were in small group seminars dealing with aspects of life beyond graduation. I don’t even recall what that session was about. But I remember clearly that it struck me quite suddenly exactly how physical my chosen field of surgery really was. That, unlike my friends and classmates who were heading towards other fields, my ability to do my job as a surgeon was going to depend not just on my will and intellect, but on sheer physicality and functioning senses.

A surgeon has to be able to stand at the operating table; both hands and arms need to function. Senses have to work — vision, hearing, speech, touch. Unfortunately, smell too. (I wish I had known about smell, although it probably would not have deterred me, just prepared me.) I realized it is a very, very physical job. Losing the function of any one sense or limb could alter the ability to operate, the ability to be a surgeon. Internists can still practice from wheelchairs or with accommodation for myriad physical or sensory impairments. Other specialties that perform procedures retain their full professional identity and ability to continue in those fields, even with limited ability or inability to perform.

But, what is a surgeon who doesn’t operate? Continue reading

Remembering a Friend, Forever Young

“May you stay forever young…” Forever Young, Bob Dylan

“Eonia i Mnimi (Eternal Memory)” -Greek Orthodox Funeral Chant/Hymn


Maine coast, morning fog

In the holiday season and as the year is drawing to a close, a paradoxical melancholy creeps in amidst the celebrations and holiday cheer. We take even a brief moment to pause and reflect on the past year and on past holidays. It is a good time to dwell a little while with those memories.

At this time of year, social media is rife with posts and alerts reminding us all to be kind and gentle, sensitive to those around us who are in pain. There are many for whom the holidays bring no joy, no cheer, and symbolize stress and loss. We are asked to be on alert for those who may be in crisis instead of celebration.

In health care, it seems as if this time of year ushers in a spike of tragedy. More stress over more severe illness, more sadness over profound losses. It seems more acute, more raw, more shocking, as these sad events play out in stark contrast to the festivities celebrating the joy and cheer of the holidays around us. Even if the numbers don’t bear this out (though they might), it is this sharp contrast between joy and grief that etch these memories more deeply in our minds.

These memories color our reflections of the holidays. They are good reminders to be aware and sensitive to those around us.

Today’s musings are more personal than medical.

Continue reading