The Ultimate Patient Advocate

Posting my piece written for Sermo, as a guest blogger on the Sermo Blog, April 13, 2015. Click on the link here (The Ultimate Patient Advocate)to see the original post. 

Adding the quotes to set the tone, though, as I usually do. The graphic is also my own photography, as with all of the pictures on this blog. Enjoy!

 

“Only one rule in medical ethics need concern you — that action on your part which best conserves the interests of your patient.”Dr. Martin H. Fischer, German-American Physician and Author

“A physician shall, while caring for a patient, regard responsibility to the patient as paramount.”Principles of Medical Ethics, American Medical Association

“I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else.”Fellowship Pledge, The American College of Surgeons

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Laurel, North Andover, MA

Advocating for patients is a core value in medicine, in patient care. Our legacy as patient advocates dates back to Hippocrates in 500 B.C.E., codified in the oath and teachings that have provided the moral and ethical foundation on which the profession has been built. Even the Code of Conduct for the American College of Surgeons includes as its first principle, “Serve as effective advocates of our patients’ needs.”

Physicians fundamentally care for patients, their families, our communities. We advocate on the small, individual scale for each patient, and we advocate on the large scale for the entire population of patients and society.

The physician is the ultimate patient advocate.

The entire purpose of my profession is to learn about humans—their biology and chemistry, their function in health, and dysfunction in illness and injury. We strive to understand the impact of health or illness and injury on the psyche and on social interactions. To learn about and discover treatments and interventions, and to provide compassion and comfort in applying them. To educate both patients and our society in order to prevent illness and injury, promote health. We are called to speak truth to power in order to accomplish these goals.

The foundation of all this is the relationship and trust between the physician and the patient. Central to this relationship, that trust is the role of the physicians as advocates for their patients.

But now the position of “Patient Advocate” has become ubiquitous among hospitals, insurance companies, and health systems. A Patient Advocate is a (lay) person/entity whose primary role is to protect the patient and their interests, but also to field complaints, advocate on behalf of the patient/family, and even go so far as to assist in decision-making regarding the treatment plan or course of care. They are supposed to help navigate the often complex and confusing healthcare system, and the interactions with doctors, hospitals and insurance companies.

Patient advocacy seems a noble pursuit, and often much needed. Patients and their families are distressed and vulnerable, even in good health; add illness, and the ability to navigate the system and the decision-making can be daunting if not impossible.

All well and good, but I wonder why there is this pressing need for an entire different profession, an additional layer, another buffer between the patient and the physician? Has the core principle of advocacy changed in my profession? Have we abdicated our responsibility, or is it something else? If it has not changed, if we have not abandoned our principles, what is it perceived as lacking?

As Voltaire (or Peter Parker/Spiderman’s Uncle Ben) says, “With great power comes great responsibility.” The powerful responsibility physicians have for the care of their patients remains, but the trust on which it is based has eroded. The bond between physician and patient — and between the medical profession and society — has become strained.

Individual patients, the general public, and the government have all become increasingly wary of physicians. Considerable effort and expense is employed to rein in the perceived power and control wielded by physicians, implying that there is little trust in the ethics, oaths, and codes that we have set for ourselves. Hospitals, healthcare organizations, insurance companies, and various branches of government and regulatory agencies, as well as licensing boards and health departments (not to mention lawyers) have bit by bit surrounded physicians and buried them under mountains of law and regulation, benchmarks and measures and protocols.

Health systems and insurance companies increasingly dehumanize physicians, treating the highly skilled and highly trained professionals like pawns on a chess board, faceless and interchangeable. Physicians drop on and off of “preferred provider” lists in arbitrary and capricious fashion, destroying any relationship and continuity built with the patient. Doctors are presented as interchangeable.

Worse, at times it seems that these groups are driving a wedge in the physician-patient relationship. As a consequence, patient trust and confidence is shaken. It is not much of a leap for the relationship to be framed then as adversarial rather than cooperative. If a doctor is no longer seen as the patient advocate, then of course the void must be filled.

But Patient Advocates generally haven’t the medical training or expertise. They may be also beholden to the system or entity that employs them. The most common and available advocates are generally working for a hospital or insurance company, whose priorities may not entirely align with patient and physician. This is problematic, of course, because it is often the hospital or insurance company the physician must stand up to on behalf of her patient.

It is imperative that physicians continue to shape our evolving healthcare system and promote that which preserves and protects our relationship with our patients. We must insist that we not only take a seat at the table among “stakeholders” in the healthcare system, but show that we are the best and more uniquely qualified to lead the efforts. We must again claim that space between patient and physician and remind not just our patients, but all others that indeed we are their advocates. The physician who fails to serve as an advocate for their patient also fails to serve as a physician to that patient. We must fight for the time we need, fight against the distractions, shore up the trust that has been strained so mightily.

There is nothing in the description of a patient advocate that isn’t already part of what we as physicians commit to do for our patients. We are, therefore, the first and the last patient advocate, their most effective advocate, the ultimate patient advocate.

I advocate for physicians to continue to claim the time and space to be effective advocates for our patients; and to embrace this responsibility, and not abdicate it to others. Taking the lead to work with, but not be replaced by patient advocates.

A Different Kind of Mentor

This is my “mentor piece” that was written for the Association of Women Surgeons, and published on their blog April 22. 2015. Click here to link to the original post. The quotes and picture on this version are my own addition, like I always do. Enjoy!

“The greatest good you can do for another is not just to share your riches but to reveal to him his own.” –Benjamin Disraeli

Have a little faith in me…” – John Hiatt

“If you’re lucky enough to do well, it’s your responsibility to send the elevator back down” – Kevin Spacey

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Swans, Rockport, MA

Mentorship in medicine and surgery was not always formally acknowledged and promoted. Today not only is it acknowledged and promoted, but also the importance of mentorship for professional development through the arc of a career is stressed. However, for many women, the one-to-one relationship of the classic mentor-protégé remains elusive, complicated by gender and generational differences. This has been especially true for the groundbreaking women before me, and for some remains true even today.

In a very real and tangible way, the Association of Women Surgeons has been a mentor to me, and perhaps to other women surgeons as well. The mission of the Association of Women Surgeons is “to inspire, encourage and enable women surgeons to realize their professional and personal goals.” This sounds a lot like the description of a mentor. (The AWS even publishes a book entitled “The Pocket Mentor”).

So that begs the question, can an organization itself be a mentor? I would assert that it can be.

Mentorship and the mentoring relationship overlap and encompass many other roles. One can have more than one mentor, each for different activities or components of work and career, or just one mentor to help with the big picture. Role model, professor or teacher, advocate, coach all come to mind, and mentors may be any or all of these to some degree. A mentor provides encouragement and support, advocacy and sponsorship; they guide and educate. The relationship between a mentor and protégée is notable for longevity over time.

These sorts of professional relationships formed in the past as they do now, but they were spontaneous and organic, as junior- and senior-level individuals naturally gravitated together, bonding over shared interests or goals. However, mentorship was not well defined or delineated, not identified beyond one of its component functions of advisor, teacher, proctor or coach. The mentoring relationship retains that spontaneous and organic nature; it can’t be forced or assigned. Unlike then, however, there is encouragement to go and look for mentors. You will never find these relationships if you don’t look.

I certainly had role models and champions along the way as I moved through the stages of my education. Teachers and professors and coaches, residents and attendings who took an interest in, supported and encouraged me. To them I am thankful and grateful. But there is an important part of the definition of mentorship, the concept of developing and nurturing the relationship and the guidance over time, that differs from these relationships. Mentorship as I understand it is different, and it is more.

Women in surgery remain a minority, more striking as one advances through the ranks, just as striking in community practice as in academia. Whether academic rank or leadership in societies and organizations, the farther up the ladder you go, the fewer women you see. This is mirrored in community and in private practice, where there may be no women at all, or maybe just one. I am hard-pressed to think of many practices outside of breast surgery with more than one woman. A surgical practice may strive to have a woman, but rarely more than one. In fact, often if a community has more than one woman surgeon on staff, these women will usually be found in different specialties.

This is very isolating. Although we have much in common with our female colleagues in other specialties and other professions, there is much about surgery that remains unique and uniquely challenging. We seek mentors to help us navigate the day-to-day challenges as well as to help guide the trajectory our career. Many of us have had meaningful guidance and mentorship from men, but since it’s a given that our male colleagues can’t truly understand the challenges unique to being both women and surgeons, their help can only go so far.

This is the void that the Association of Women Surgeons fills. Into this place the organization steps in, as a surrogate for an individual mentor.

As a group, the AWS makes good on the promise of its mission statement, taking the form of conferences, lectures, networking, committee work, and publications. Since the AWS first came together, the organization has been there for all women in surgery, at all levels. Along with other similar groups, the AWS has deconstructed the dynamics of the “good old boys network,” identifying and promoting both theory and practice of networking. Indeed, I believe by shining the light on mentorship, we now pay attention to it.  Mentorship is deconstructed, defined, and promoted. Our students and trainees seek mentors. I don’t think this is a coincidence that the attention to mentors and mentorship has paralleled the activity and growth of women (and their organizations) in medicine and surgery. This benefits not just the young women in medical school and residency, but all physicians in all levels and stages of career, male and female.

Today there are opportunities for women in surgery to find each other and connect, especially with the expansion of social media. Organizations like the AWS catalyze this. The challenges going forward are to harness the power of technology and social media to continue to connect, to network, to support, and to form mentoring relationships. To increase involvement and engagement in the core constituency of general surgery (as the meeting piggybacks on the American College of Surgeons annual Clinical Congress), and meaningfully include women in all of the surgical specialties, including GYN surgery, where a parallel organization such as ours does not exist.

Our numbers will continue to grow, so will our influence. The fellowship and support of the Association of Women surgeons is the surrogate mentor for all of us as we continue to chip away at the glass ceiling, and provides the structure for those who do break through to send a ladder back down to offer other colleagues a rung to stand on and a way up.

Little Miracles

“There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle.” Albert Einstein

“Miracles happen everyday; change your perception of what a miracle is, and you’ll see them all around you.” — Jon Bon Jovi

“The miracle is this: The more we share the more we have.” — Leonard Nimoy

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Sand and Sky, Summer, Ocean Park Beach, Maine

It is amazing when things in medicine work just the way they are supposed to —  it’s like a miracle.

When I take an antihistamine, I can breathe, and all the itching and sneezing stops. When I get an injection of local anesthetic, I can touch and poke and pinch to test that it is working — and it is. When I had an operation on my knee, an ACL repair, my knee stability was noticeably restored almost immediately, despite the post-op pain and swelling. I know these things work on patients, because books, observations, and experiences have shown me so. As a surgeon I get a kick out of operating on acute appendicitis, where often even in the recovery room immediately after surgery, the patient already feels better.

Yet I still marvel when I notice that this stuff is working on me.

I used to worry that as I entered the world of science, and then medicine, I would lose the ability to see beauty, to appreciate and be amazed and awed by the world around me. I worried that the more I knew about the details of how things worked, that I would not be able to see the glorious whole, the big picture, whatever that big picture might be.  Would the biology and chemistry and biochemistry and physics become like a filter on a camera lens, changing the way I would see these things? As I got deeper into this world of science and medicine, and then surgery, I was concerned that the experiences around me might overwhelm or blunt my humanity,  become mundane. Would I  become callous, detached, dispassionate? Would I still feel? Would I lose my faith, whether in people and humanity, or even more? Continue reading

Muted

Smitty greets Sully as they meet to head to work, “Hey there, Sully! How’s your wife?” Sully answers, “Oh, geez. She’s up in bed with laryngitis.” Then Smitty says, “Laryngitis?! That damned Greek!”

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First cone of the season, West Boxford, MA

As you may have guessed, I am nursing a case of laryngitis, my voice muted and strained. This time, it has not stopped me from attending to my work responsibilities or other activities. It has required some adjustments though, as I squeak and growl and cough and sputter, my voice robbed of inflection and tone, and even volume control. It is an irony to have to strain my voice to repeat myself because of my strained voice.

I have had more severe laryngitis twice, one time a couple of months ago, another time several years ago. These were so bad, my voice so completely silenced, that I had to change both my operative and office schedules, not just to recover, but because it made my job impossible. We wear masks in the operating room which obscure our expressions and hide our mouths, muffling our voices just a bit; it can be difficult to hear and be heard even with functioning vocal cords. It is impossible if you can’t even manage a whisper.

It is true that learning to (or being forced to) mute your own words and listen more to patients — and colleagues and staff — is not a bad exercise in attention and communication. But in day-to-day practice, there is an expectation of bi-directional conversation, two-way discourse. The doctor is expected to voice opinion, advice, orders. That cannot happen while mute.

In medicine and healthcare we often think about, and talk about, physician-patient communication, but in the abstract. We consider principles and philosophies, we argue the the importance and the need to protect and enhance physician-patient communication. We frame it as a component of the physician-patient relationship, or patient empowerment, or patient-centered care, or patient education, or even informed consent. It will probably be an important piece of the new precision, personalized medicine buzz. Physician-patient communication is the foundation for much in healthcare, whether new hot topics and ideas, or old traditions and approaches.

There are lots of little things we tend to overlook though, in these lofty discussions, that turn out to be no less important when considering the big picture of physician-patient communication, and the big important overarching principles and approaches. Think for a minute about the old saying about trying to sleep with a mosquito in the room, and you will start to understand about small things having great importance, great impact.

These are the small, day-to-day, practical and concrete challenges and barriers to communication, to care. The little things that will tank the most cutting edge and sophisticated solutions and approaches. They could be episodic, like a surgeon with laryngitis, a power failure, downed cell tower or phone line, crashed computer network or server. Or they could be more insidious, lurking continuously in the background, like scheduling protocols that cut time short, technology mismatch when the patient may only have an analog phone, or no phone at all, outdated computer software or no computer at all, no car or transportation, no family. Even language itself may be a barrier rather than a bridge, whether a function of nationality, education, or med-speak jargon.

These little things are potent, despite being small; they are common, nearly ubiquitous. If not accounted for, and certainly if not acknowledged, they may well allow our new solutions to enhance rather than alleviate the disparities and vulnerabilities among those who are most susceptible. We must keep them in mind as we debate our philosophies and principles, as we race towards new technologies and systems.

Disrupting and hacking the systems are popular concepts that are catching our attention and imagination. But if we aren’t careful, the disruption we seek will not be the disruption we get. Remember unintended consequences. Remember that if we aren’t mindful to craft solutions that will include and work for the most challenged and vulnerable among us, the solutions will not likely work well for any of us, and the whole enterprise crashes down, grinds to a halt.

Just like my schedule on the day I am mute from laryngitis.