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.

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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.

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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.

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A Matter of Faith

“Have a little Faith in Me” – Have a Little Faith in Me, John Hiatt

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Russian painted wooden Easter eggs

Spring ushers in major holidays in many faiths and religions. Western Easter has just passed, we are in the midst of Passover, and coming to the close of Holy Week with Good Friday for Eastern Orthodox Christians, making final preparations for their own Easter celebration.

The rites of spring and the vernal equinox, new life and rebirth are springtime themes and touchstones across many cultures. Faith is important to many people and across many cultures and religions. I would assert faith is even important to atheists and agnostics, and those without a formal religious tradition.

Faith is important in medicine, too. Continue reading

Thoughts on Doctor’s Day

“Clowns to the left of me, jokers to the right. Here I am, stuck in the middle with you!” – Stuck in the Middle with You, Steeler’s Wheel

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Daffodil between the rocks, Spring 2014, North Andover, MA

Today is Doctor’s Day, established to take a moment to recognize and honor the work and contributions of doctors.

The first thing I read today was a message from current Massachusetts Medical Society President, Dr. Richard Pieters, who in speaking about Doctor’s Day reminds us all that the focus of the day is not just physicians, but the physician-patient relationship. The physicians of the Massachusetts Medical Society have declared that this Doctor’s Day we recognize “the basic principles that the doctor-patient relationship is confidential and sacrosanct.”

In his piece, which discusses this in the context of gag laws preventing physicians from asking about gun ownership and gun safety in the home, he emphasizes the efforts of physicians to focus on the patients and have unencumbered and protected conversations. It is impotent to protect both directions of these conversations—patient to physician as well as physician to patient. He further stresses the importance, and danger, of government laws, rules, and regulations that would insert themselves between physician and patient, silencing physicians or compelling them to include specific proscribed content.

I could not agree more. I would in fact go even further. 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

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

Context is Everything: Communicating Meaning in Medicine

“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?

In a Blink: ‘The Diagnosis Is Cancer’

“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