Doctors

Like a Surgeon: About That Surgical Stereotype

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“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

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“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 →

Working Christmas: On ‘Being Essential’, Together

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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

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“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

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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

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“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 →

In a Blink: ‘The Diagnosis Is Cancer’

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“Life changes in the instant. The ordinary instant.” -Joan Didion

“Maybe that’s what life is…a wink of the eye and winking stars.” -Jack Kerouac

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Sunrise, Plum Island/Newbury, Massachusetts (November 2011)

Life changes in a blink. A misstep, an accident, being in the wrong place at the wrong time. The seconds and even microseconds seem an eternity. Nothing will ever be the same from that moment. Everything that happens in that instant, flash, blink,  changes the whole world, your whole world, and you can never go back.

A few weeks ago I was in an automobile accident, my friend was driving. It was on a highway, at speed, involving two other cars besides ours. Amazingly, no one was hurt (I assume this, since the culprit who caused the wreck kept right on going and never stopped). The cars were damaged, my friend’s car took the worst of it. It is in the shop so that it can be fixed up, as good as new. All of this happened in a blink, an instant. Too fast to even register what was happening. Our plans for the day were shattered. My friend will be dealing with this for months, by the time all the repairs are done, bills paid, insurance adjusted. But cars can be fixed, as good as new. This is what got me thinking.

Injury, accidents and trauma, illness represent a nearly universal experience. No one is spared, Continue reading →

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

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“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

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“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 →