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.

Friday Afternoon Rituals—Here Comes the Weekend!

Party Weekend” – Joe “King” Carrasco

Fight for Your Right (To Party)!” – Beastie Boys

“We Just Wanna Dance” – The Flirts

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Mom & Dad’s dog Sophia, too pooped to party…

My favorite radio station, WHFS, had a ritual every Friday afternoon to start off the weekend, back in the day. DJs Weasel and Bob Here would exchange pleasantries as they exchanged shifts, and would launch in to the same set of songs at the same time every Friday (with occasional additions). The songs above, as a matter of fact. These were selected to get your spirits up and blood pumping as the work week morphed into the weekend. It was a ritual which became a tradition for ‘HFS and loyal listeners, fondly recalled to this day, even though the radio station itself is long gone and the DJs dispersed. Every Friday I seemed to be in my car at just the right time, cranking up the volume, celebrating the end of my week and the coming weekend.

Doctors also prepare for Friday afternoons, bracing for a ritual of sorts. Any time after 3:00 it starts, lasting until well after the offices close and the weekday schedule transitions to the after-hours weekend routine. It is observed by most physicians, regardless of specialty, whether they practice in the hospital or in an outpatient office.

Suddenly on Friday afternoons, it occurs to people that the weekend will be starting, and the availability of the doctors and their offices, labs, imaging, testing and what-have-you will be limited. So all of the problems languishing in and out of the hospital take on a renewed sense of urgency, and must be taken care of Right Now, before the weekend hits. Nothing can wait another hour or day, and certainly not until Next Week (Monday)! Continue reading

The Paradox of Physician Communication

“Communication Breakdown, It’s always the same, I’m having a nervous breakdown, Drive me insane!” – Communication Breakdown, Led Zeppelin

“Oh why can’t we talk againDon’t leave me hanging on the telephone!”  – Hanging on the Telephone, Blondie

Carriage line, Jackson Square, New Orleans, LA

Carriage line, Jackson Square, New Orleans, LA

I honestly don’t know how they did it, how doctors practiced and communicated effectively in the days before our modern technology, with computers, pagers, and cell phones (not to mention laptops, iPads and tablets, and smart phones), but they did.  All of these have been a ubiquitous presence my entire practice career; each has insinuated itself rapidly and completely into the lives and practices of physicians.  I think most physicians would feel lost or disoriented trying to practice without all of this technology today (well, maybe not pagers, which are phasing out rapidly as cell phones and smart phones leave fewer gaps in coverage).

There are so many ways to be in touch and in communication today, making us available at any time, in any place, limited only by the reach of our devices.

It certainly feels as if physicians live their lives constantly plugged in and available, all of our devices turned on even if we are off. We feel as if no time or place is sacred or spared, and must make it clear to others and arrange those times when we must be free from interruption. Even then, there is a barrage of communication that awaits us when we plug back in. There is an expectation of constant and uninterrupted availability. There is anxiety when the communication fails — a dead battery, or poor signal when we thought we were in a place with coverage — only alleviated when we are once more connected.

So with all of this ability to communicate, all of this technology, our electronic leashes keeping us tethered, why aren’t we communicating with each other? Why is our communication so ineffective? Continue reading

Running Late: Confessions of the Late Doctor

“I’m late! I’m late! For a very important date! No time to say hello, goodbye! I’m late! I’m late! I’m late!” – The White Rabbit, Disney’s Alice in Wonderland 

“Oh dear! Oh dear! I shall be too late!” – The White Rabbit, Lewis Carroll’s Alice in Wonderland

“Which form of proverb do you prefer Better late than never, or Better never than late?” – Lewis Carroll

“And it’s too late, baby, now it’s too late, though we really did try to make it.” – Carol King, It’s Too Late, Tapestry

Clock Tower, Mary Lyon Hall Mount Holyoke College, South Hadley, MA

Clock Tower, Mary Lyon Hall
Mount Holyoke College, South Hadley, MA

It is in the very words, running late. It is not walking late, or strolling late, or even meandering late. It is always running late, the phrase itself active, implying urgency and speed, rush and anxiety. The distress, just like the White Rabbit. The dash to the next appointment in a crammed tight, overfilled schedule.

Running late. It is the bane of doctors everywhere. I can’t stand it, I don’t think any doctor is happy when it happens. It is distressing, and feels unavoidable. I feel as if I can’t stop it, can’t prevent it.

It is almost to the point that I am amazed if I am ever actually on time. Office schedules overbooked to compensate for no-shows and to accommodate urgent patients, and operations are scheduled with an optimistic slant on the time needed. All of it collapsing with the first surprise, the extra problem, the emergency. The schedule so carefully crafted, like a house of cards, and just as vulnerable to come crashing down at the slightest perturbation, the tiniest shift. These shifts and adjustments snowball throughout the rest of the day, bigger and bigger, later and later, sweeping me along the avalanche path.

Run, run, run. Rush, rush, rush. Office to hospital, hospital to office. Continue reading

Like a Surgeon: About That Surgical Stereotype

“A good surgeon also has to have compassion and humanity, and not be someone who is arrogant and difficult to deal with.” Dr. Thomas J. Russel (former Executive Director of the American College of Surgeons, New York Times interview

“Like a Surgeon” – Weird Al Yankovic

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Operating, like a surgeon.

I hear the comments frequently; in fact, I hear them all the time. At work I hear them from staff, from patients — even from non-surgical colleagues. I hear them away from work, when meeting new people who find out that I am a physician and a surgeon. I think many women surgeons hear the same:

       “You’re not like a surgeon. You’re not like other surgeons.”

The comments tend to run along the same lines. You don’t look like a surgeon. You don’t act like a surgeon. You’re too nice, too caring, too compassionate, too thoughtful, too communicative (sometimes, too pretty). Most of the time, the comments are offered as compliments. They are proffered in a context attempting to make me feel welcomed and appreciated.

I understand these comments are meant as compliments, but what do they say about surgeons? And even more specifically, about women who are surgeons?

We all have stereotypes.  They are a shortcut we all use to help us understand the people and world around us, especially the unfamiliar. But the unfamiliar becomes familiar, and people and groups evolve and change. Stereotypes are mired in ignorance and misinformation, and they help us to resist that change. At that point they do not serve any purpose, and in fact, harm rather than help.

These comments and compliments speak to the stereotypes of who we think our doctors are, what surgeons are like, speaking volumes about the image of surgeons. It is an image as unfair to men as it is to women. Continue reading

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

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

 

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(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

 

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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