The Entourage: Between Surgeon and Patient

“Two’s company, Three’s a crowd.”  -popular saying

“But I always say:  One’s company, Two’s a crowd, and Three’s a party!”  –Andy Warhol


100_3568 - Version 2As a surgeon, my patients generally know they are seeing me for a problem, and that problem may require surgery. I am sensitive to the fact that this is a very big deal to them, often the first time they have ever seen a surgeon. Even if they have had surgery before, that only means that they may have some idea as to what the process may entail. Patients are nervous, perhaps frightened, they have questions. They know they will have more questions and concerns as the visit and process moves on. There are big and important decisions to be made.

Many patients therefore arrive to their first visit with an entourage, one or more family members or friends, companions who are there to lend emotional support for this stressful visit. The additional ears to make sure the explanations and descriptions are heard correctly and understood, the extra minds to pose questions the patient may have forgotten or not thought pertinent to ask. This is laudable, advisable. I encourage patients to have someone with them for just these things, to help the patient.

So here is why the first thing I do when I meet a new patient is to excuse the entourage, and send them right back to the waiting room. Continue reading

Lessons From Zachary: What a Physician Learns From the Death of a Dog

“You think that dogs will not be in heaven? I tell you, they will be there long before any of us.”Robert Louis Stevenson


My dog died three years ago today.  On this day I will remember him, and share a little bit of him with you. These are the lessons from Zachary that I learned during that fall three years ago, on the final leg of our journey together.

Zachary was the first dog of my very own. He was a flat-coated retriever, and a fairly typical example of his breed. Typical of the breed’s “Peter Pan” personality, never growing up. Smart and energetic and goofy and quirky and unique, all of which made him an absolutely typical flat-coat. I could write on and on about his qualities, both endearing and frustrating, and regale you with stories. We would have some good laughs. But let’s save that for another time. We will also hold off on discussing grief, or mourning pets, or the role of pets in our lives.

Let’s just say my dog was a very good dog, and that I still miss him.

He was diagnosed with cancer around September 17, 2011, and died on November 15 of that same year. I learned a lot in that eight weeks. He had malignant histiocytosis, a cancer for which flat-coated retrievers and Bernese mountain dogs share a genetic predisposition, as yet to be defined. It is an otherwise rare cancer, but it is also a rare and difficult-to-treat cancer in people. In fact, there is research at the NIH, as an offshoot of the Human Genome Project (the Canine Genome Project) which studies this cancer in hopes of unlocking the secrets to aid in testing, diagnosis, and cure –for both people and dogs. This research is in part funded by Flat-Coated Retriever and Bernese Mountain Dog breed groups. Zachary was able to contribute to this as a healthy youngster, and again later after he was diagnosed, in his final moments. My choosing to participate offered me some comfort at the time, and still does. Untreated, dogs usually have a life expectancy of 2-6 weeks; with treatment, that can extend up to 6 months, give or take. Zach did not respond to treatment, to put it mildly. He did not tolerate the chemotherapy. He made it 8 weeks from the time of diagnosis.

As a surgeon, I am no stranger to death and dying. I treat cancer patients nearly every day. I have cared for many patients and their families, from the initial biopsy on to the end. I thought I would be well equipped to handle this, given my background and experience. I understood the concepts and differences between treatment and cure, palliation, and hospice care. But I soon realized that I still had a lot to learn. I am still surprised at how much I had to learn, how different it was in dealing with my dog whose life was slowly and inevitably slipping away. Continue reading

Storytelling: The Story Unravels in the EMR

“Storytelling is important. Part of human continuity.” –  Robert Redford



(Storytelling, Part Two) The history and physical, the progress notes, the testing are combined in the medical record, weaving these threads together to form the narrative that is the story of the patient. The electronic medical record (EMR) represents a threat to that, and the story unravels.

It is no wonder, and should come as no surprise, that many doctors in general, and myself in particular, buck and chafe with the imposition of  the EMR that is nearly ubiquitous in hospitals, and physician offices and clinics.

Most systems are unwieldy and do not integrate well into the work flow, especially in an office or clinic setting. So either the physician continues on with the old processes, saving the charting for later after the completion of the visit (which has some problems with recall, workflow, and time management, as you might imagine), or the physician’s nose is buried in the laptop or tablet device, focused on clicking the right boxes, the right templates.

In both circumstances, the narrative breaks down.

The heart of this narrative is derived from the communication between the physician and the patient, both verbal and non-verbal. This builds trust, the foundation of the physician-patient relationship, trust that is built by the attention to their story, taking the time to listen. Maintaining eye contact, reading body language. For all too many patients, this may be one of the only times and places in their life where someone does, in fact, listen to what they have to say. When you can’t pay attention because of the computer in front of you, or because you can’t take the time because you have to get to the chart and the next patient (or both), the communication breaks down, the bond begins to strain–if you were even able to establish a bond in the first place in these circumstances.

Make no mistake, patients notice this. They don’t like it, either. Continue reading

Storytelling: The Physician As Writer

“Every day, I write the book…”  Elvis Costello



I write every day, but somehow have not considered myself a Writer. I am a physician, a surgeon. I take care of patients. I operate, I admit patients to the hospital, I consult. I order tests, labs, images; I do physical examinations, I take medical histories. And I write it down.

I gather all of this information, and more than simply recording the list of symptoms, physical findings, and results, I convey the narrative of what has happened, what is going on, the interpretation, the plan. So, maybe I am a writer. A biographer, of sorts, telling the story of every patient I see, at least as it relates to their health or illness. Synthesizing the data, the history, the laboratory and test results, the imaging–into a narrative that not only explains how and why the patient got here, but also what I think is going on (and what is not going on), what it means, and what we are going to do about it (whether that means fixing it or figuring out what else we need to do). All of this are chapters in the story I am telling, to communicate the information, my thoughts and reasoning, my plan to my colleagues. The original, and still primary, reason for the patient chart (whether electronic or paper), the medical record is Telling A Story.

This special “biography”, the history, is an extremely important piece of this story, of caring for patients. All of the testing in the world–labs and imaging and what have you–are really only in support of, augmenting, what is learned in the history, and can not and do not replace it. My wise professors and teaching attendings held to this, and demonstrated it; it has been my experience throughout my own practice and career. They maintained that about 90% of what was really happening with the patient could be ascertained from a skilled, well-done history.

This takes time to do, time to master. And although this percentage may be a bit inflated, so as to impress the young minds under their tutelage, it does not diminish the importance. Continue reading

What’s in a Name

A rose, by any other name, would smell as sweet.  Wm. Shakespeare, Romeo and Juliette
A rose is a rose is a rose.  Gertrude Stein

IMG_1551“This is Dr. Hughes” or “Hello, I’m Dr. Kathy Hughes” — This is how I answer the phone, or introduce myself as I walk in to a room.

I think it matters what I am called, how I am addressed. It also matters what I call you, as my patient, and how I address you.

Any Tom, Dick, or Kathy  can be Tom, or Dick, or Kathy. But it conveys a special role and relationship to use one’s title or formal name. Not everyone can be Doctor to you, and especially not Your Doctor. It is a special and particular relationship that I have with you. I’m your Doctor, I’m your Surgeon, I’m Dr. Hughes.

And in addressing my patients as Mr., Mrs., Ms., or Dr. (perhaps only with the exception of the very young and the very old, where stage of development or dementia interfere) I also convey and acknowledge the special relationship they have with me.

I admit, I still call my parents Mom and Dad; my aunts and uncles have likewise retained those titles. And even to their chagrin, I use the formal titles to address my parents’ friends, and my old teachers and professors. It’s not just a reflection of how I was raised, but an acknowledgment of the special bonds and relationships in this part of my life, too.

It is important to acknowledge these relationships and bonds. How you address someone, what you call them, does that. It is like a shorthand, a shortcut, spelling it out. It honors them–the relationship, the bond, the person.

I remember a lot of eye-rolling and joking at the expense of the early feminists in the Sixties and Seventies, when they objected to what they felt were sexist titles and names. So work titles like “Mailman” evolved to “Mailperson” to “Letter Carrier”; first year college classes changed from “Freshmen” to “Freshpersons or Freshwomen” to “Firsties” (at least at some Womens’ Colleges). But as silly as some of this seemed and seems, the feminists had it right–there is power and identity in what you call something or someone, or how you refer to them; power in naming. Likewise, the kind of naming, or failure to name, can do the opposite, diminishing power and instead offering disrespect, even contempt.

I confess that I bristle when I am called by my first name by a patient or their family member if I have not invited them to do so. Continue reading