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.

The Convert: The Doctor Embraces Social Media

“Waaaah-Hoo!!” – Slim Pickins as Maj. ‘King’ Kong, riding the bomb in “Dr. Strangelove”

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St. Louis Cathedral, Jackson Square, New Orleans

I am converted. Like many doctors, I was very leary of social media, wary about using it, skeptical of its professional value. Especially Twitter, but really all of the platforms. No longer: I have embraced social media, and it has embraced me.

I feel a little bit like Dr. Strangelove, only the subtitle is now “How I Learned To  Stop Worrying and Love Social Media.”

Like most converts, I find myself an enthusiastic proselyte, spreading the good word to friends and colleagues, regaling them with my new-found experiences using Twitter, Facebook, LinkedIn and the like. Discovering more sites and platforms, like Sermo, Doximity, Docphin, and Medstro, to name a few. (Disclosure: I have no financial or other arrangement with any of these, but have written for both Sermo and Medstro, and am a discussion panelist later this month on Medstro). The list goes on and on, and keeps growing. Websites and apps abound; they all go mobile, so much content to explore. So much time to waste!

“Waste of time” is the most common and scathing criticism leveled at social media by my physician friends and colleagues who have not yet seen the light. 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

Is There a Provider in the House?

“I said Doctor, Doctor, Mr. M.D. – Can you tell me what’s ailing me?” – Good Lovin’, The Grateful Dead

“I’m a doctor, not a mechanic.” – Dr. Leonard “Bones” McCoy, “Star Trek”

“I’m not a doctor, but I play one on TV. ” – Chris Robinson/Dr. Rick Webber of  “General Hospital”

 

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Ceiling, Bellagio Hotel Lobby

I enjoyed an email exchange with a couple of long-distance friends the other day, Gina (an author and journalist) and Eric (a computer/IT professional), prompted by the follow-up questionnaire Gina received after her recent doctor visit and procedure. Throughout the form, it asked her to evaluate the various aspects of her interaction with her provider. 

This struck her as odd and funny, and we engaged in a generally humorous exchange. A couple of really serious points were made as well.

First, though, it made me think of a new game, playing around with words. Take any fictional character from books, film, television; any famous poetry, literary passage, or song lyric; any famous person or historical figure that contains or references the title “doctor” or “physician”, and substitute “practitioner” or “provider.” Dr. Who, Dr. Strangelove, Dr. Zhivago. Christ the Physician. Dr. Spock (both of them), Dr. Koop. Dr. Gawande. “Doctor, my eyes…”, “Doctor, Doctor, tell me the news…” , “Is there a doctor in the house?” You get the idea. Stilted, clumsy, and the result is often strange if not creepy. We can play the same game with references to the word “patient”, substituting “customer” or “client”.

But wait, we already play that game, it is a daily interaction, and we are getting shockingly accustomed to it. 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

In Harm’s Way, the Tradition and Legacy of Medicine

 “There isn’t any such thing as an ordinary life.” – Lucy Maud Montgomery

“Heroes are ordinary people who make themselves extraordinary.”Gerard Way

Clouds, Sunset after winter storm, Falmouth, MA

Clouds, Sunset after winter storm, Falmouth, MA

My colleague, Dr. Jesse Ehrenfeld, is currently on leave from his academic anesthesia practice as well as from his post as Speaker of the House of Delegates for the Massachusetts Medical Society to serve as Lt. Commander Jesse Ehrenfeld, Combat Anesthesiologist in Kandahar, Afghanistan. We all appreciate the sacrifice he is making, putting himself at risk and in harm’s way.

This sacrifice is part of the great tradition of medicine, a tradition that compels physicians into war zones to take care of the injured. It is the same tradition that has us traveling to help treat diseases for which we may not have a cure or even a name yet, or into areas near and far ravaged by natural disasters.

As physicians we imagine that the risks we take are contained in far-flung locations or defined by the time it takes to start the recovery from disaster. Taking these risks is part of our  commitment and calling, our responsibility. These are not every day, ordinary events and circumstances. They are extraordinary, and we rise to those challenges, to be extraordinary ourselves to take care of them. Then life returns to normal.

But what about yesterday, an ordinary crisp sunny winter day in Boston? When at about 11 a.m. a man entered the cardiothoracic clinic at the revered Brigham and Women’s Hospital and  fatally shot surgeon Dr. Michael J. Davidson  before taking his own life. The patients, the doctors, the nurses and staff in the hospital and clinics were in the throes of an ordinary day, no grand events planned in the city, no special holiday.

In short, it was — or should have been — an unremarkable day. Continue reading

Help the Doctor! When Systems & The System Fail Physicians

“Help, I need somebody! Help, not just anybody! Help, you know I need someone, help!” –Help!, The Beatles

“We are all here on earth to help each other; what on earth the others are here for I don’t know.”  W. H. Auden

After the storm, Falmouth, MA

After the storm, Falmouth, MA

Help the doctor!”

I’m sure most surgeons have heard this exasperated statement at some point in the operating room. It is said with that special mix of frustration, irritation, and sarcasm, usually when things aren’t going smoothly. When there is fumbling or bumbling, when the assistance, the systems, the help are failing, breaking down.

That same emotional mix is permeating medicine; this statement of exasperation could well be the new rallying cry for physicians.

Since I have started to write, and to post to this blog, I have also started to read even more of the blogs out there, primarily the medical writing. Part of writing is reading. As I write about the subjects and issues and events that touch my professional life, I have noticed that many of the same are on the minds of my colleagues. They likewise broadcast their thoughts to the universe. I am conflicted, I confess. I don’t know whether I feel a tinge of disappointment that my observations and epiphanies are not so singular or earth-shattering, being shared by others; or vindicated, to see so many with similar experiences leading them to similar observations and conclusions. We each are unique, though, with slightly different angles as we approach the topics, like the facets on a diamond. But, we are all on the same gemstones, and like the facets, reflecting more light, illuminating the stone. So I will claim my facet on the gem, and hope to illuminate. I add my voice to the chorus.

One thing that shines through so clearly to me as I read, as I go to medical meetings, or even attend any gathering involving two or more physicians, is the general sense of frustration. It touches all doctors, regardless of specialty, employment status, or even level of training or experience.

It comes as no news to observe that our capital-S System is broken, and that our lowercase-s systems are failing us. I think that the root of the problems with both share a common underlying cause.

These systems no longer help the doctor. Continue reading

Changing the Clocks – Timely Observations

“Let’s do the Time Warp again!”  – The Time Warp, The Rocky Horror Picture Show

 

IMG_1911I am always a little out of sorts in the days that follow the time change every fall and spring.  I find it easier to get up in the morning when it is light out. In the fall, that is only temporary, and the light continues to slip away and fade as we pass into winter, when the days – or at least the daylight hours – are shorter. So changing the clocks only provides transient respite from the coming dark mornings.

I think people might like the idea of adding an extra hour to their day, as we change the clocks in the fall and despite the annoyance of resetting clocks, as much as they dislike losing that hour in the spring. We all imagine a luxurious extra hour of sleep, though that fantasy is usually thwarted by the reality of our schedules and our internal clocks (especially if you have pets or small children, even if your own internal clock can be ignored). Those internal clocks take frustratingly longer to adjust, so you end up simply waking an hour or so early. When we lose that hour in the spring, we almost invariably sacrifice an hour of sleep, as our busy schedules end up  overriding both lost hour and internal clock. We can be out of sorts with a side of zombie as we tackle those first few days.

The view of the time change is a little bit different for doctors, and anyone who must be on call for their job, though much of what I have just observed still holds. I can speak best to my experience of this as a doctor, though, so it is that perspective I will use. I view the time change, and much of my world in fact, through the prisms of being on call and the on call schedule.   Continue reading