Monday, December 19, 2011

Mechanics truly are doctors for cars

Last week, my car got a flat tire.  I rolled into the local dealership the next day to replace my donut spare with a new tire (along with a new tire for the opposite side, of course).

I had only that one issue on my agenda initially, but as I drove to the dealership, the little sticker in the corner of my windshield reminded me that I was overdue for an oil change.  Oh, and that non-urgent factory recall on the transmission needed attention.  It seemed like a lot to take care of, and I figured I'd probably need a return visit to get all of those issues addressed.

I was a little apprehensive about what they'd be like.  I don't speak "car" very well, you see.  I often have trouble understanding the explanations I get from mechanics, and they often don't understand what I'm referencing when I mention problems in lay car language like "a funny rattling noise."  Much like a physician, they have to ask "when does it happen?"  "how often?"  "what seems to bring it on?" to decipher my car's symptoms and obtain the information they need to diagnose and treat.  I tend to ask a lot of questions, and they tend to need to ask a lot back, which doesn't always go over well in busy carshops.

So, I was pleasantly surprised to discover that this dealership service center was my kind-of place.  Their routine check turned up some filters way overdue for a change (I confess to not being very good at remembering such routine maintenance needs), and their computer system alerted them to the transmission part recall before I could even ask about it.  They offered me a loaner car so that they could take care of the recall - and the filters, and the oil change, and the new tires - in a manner convenient to me and my needs.

And, happily, they explained everything that was going on in plain English. Patiently.  Like they had all the time in the world for me, even when it was clearly very busy there.

I would like to be that kind of doctor working in that kind of practice.  I'd like my patients to rely on my electronic record to prompt us when certain routine health maintenance needs are due.  I'd like for our office to make taking care of their healthcare needs as convenient for them as possible.  I'd like for them to trust that I will understand their non-medical story and share my thoughts back with them in plain English, while giving them my full, non-rushed attention.

The analogy only goes so far (I'll defer comment on car commercials, stereotypical car sales people, etc...), but I was fascinated by the many similarities between that car service center and a medical office.

We could learn a lot from them.

Tuesday, December 13, 2011

My BHAG for Family Medicine

I have a BHAG (Big Hairy Audacious Goal).

I want people to hear "Family Medicine" and know that it refers to a medical specialty dedicated to providing relationship-based, patient-centered health care.

I want people to know that family docs take care of a lot of complicated, challenging diseases - and not usually in isolation.  Our patients have high blood pressure, complications from type 2 diabetes, congestive heart failure, depression, chronic kidney disease, emphysema, anxiety, asthma, and coronary artery disease, to name a few; treating each of those conditions individually is nothing like treating them in relation to each other.

I want people to know that I trained for three years to become an expert in my specialty.  During my Family Medicine residency, I learned about providing preventive care.  I learned how to treat a multitude of acute problems - colds, fractures, lacerations, rashes, etc.  I learned how to deliver babies, resuscitate victims of cardiac arrest, and drop a central line into a coding patient.  I can take off your moles, skin tags, and warts.  I can remove your ingrown toenail and treat your acne.  I can obtain your pap smear, discuss your birth control options, and treat your STDs.

I want people to know that I can care for your kid and your grandparent.  I routinely counsel teens about sex, drugs, and rock 'n' roll.  I am comfortable in offices, hospitals, maternity wards, newborn nurseries, intensive care units, nursing homes, and even patients' homes.

I want people to know that Family Medicine residents learn about using the best medical evidence and the latest medical technology to guide decision-making conversations with patients. They can intelligently sift through the tremendous reams of medical studies that are published daily to pull out the information most relevant to their patients.

I want people to know that those residents learn how to work within a healthcare team.  Nurses, medical assistants, pharmacists, care managers, social workers, administrative staff - it takes all of us to provide outstanding care.  These incredibly important people are my hands, eyes, and ears into the thousands of little tasks that must get done every day in the office and at the hospital.

I want people to know that no medical specialty is as devoted to medical education as Family Medicine.  The Society of Teachers of Family Medicine holds an annual meeting devoted solely to medical student education.  We are one of only a handful of medical specialties with an entire fellowship (post-residency training) devoted to faculty development - training the next generation of academic Family Medicine teachers, researchers, and leaders.

Lastly, I want people to know that family docs do everything that they do in the context of our patients' belief systems, families, and communities.  Our specialty is the only one that mandates dozens of hours of educational time during residency about the doctor-patient relationship.  How to help folks quit smoking/over-eating/whatever, how to tell someone that the biopsy did show cancer, how to mediate family disagreements about end-of-life wishes - this behavioral instruction is just as important to a Family Medicine resident as the pathophysiology, treatment, and prevention of disease.*

If you're not a family doc, I bet you didn't know all of those things.  And the blame for that truth lies squarely with us as family docs.  Frankly, other specialties have been better than us at promoting themselves.  You all likely know what a dermatologist or a cardiologist is, even if you're not working in the medical field. Family docs can learn a lot from how other specialties have advanced the interests of their patients by advancing their specialty's cause; it's something we have failed to recognize the importance of until now.

Because of that failure, Family Medicine is not understood - and thus not valued - by the public, by politicians, by health plan administrators, and by too many of the other people who make decisions about health care in this country.

We need to show them what Family Medicine is all about.

My BHAG is to share Family Medicine with the people who don't know about us yet. I hope that this blog does that in some small way; certainly, many of the Family Medicine bloggers and tweeters out there are doing it in a bigger way.

But, I don't think that's enough.  We need more.  We need an #FMRevolution.  I have to believe that there's something even bigger, hairier, and more audacious that we could do.  I wish that I knew just what that that big, hairy, audacious thing was. Fortunately, though, I am but one of many.

It will take all of us to get the chorus of Family Medicine to echo across our nation.

* Am I saying that other specialties don't care about relationships with patients, or patient-centered care, or evidence-based medicine?  Absolutely not.  But the statements above are true: other specialties do not systematically devote protected time in residency training about these issues the way Family Med residencies do.  You could argue that other specialties don't need this training as much as family docs, do, I suppose.  But that's for a future post...this post is about trying to boldly define our identity as a specialty.  Lambasting other specialties is not on my agenda.  Advancing the cause of Family Medicine is.

Tuesday, December 6, 2011

The noncompliant patient (that was me)

I alluded to an incident in my prior post that I'd like to share more about.

For you non-docs, "curbsiding" is stopping a doc (usually of a different specialty than you) that you run into to ask their opinion about a patient case.  They don't get paid for that, of course, but it's usually a common courtesy among physician colleagues.

So, in this scene I tried to curbside one of my pulmonologist teachers and colleagues about "my patient's" (really mine) frustratingly worsening coughing fits.

The scene: busy hospital hallway.
The players: Dr. Jen (of course) and Dr. K, prominent pulmonologist well-known to myself and the rest of our community hospital.

Dr. Jen:  "Dr. K, can I run a patient by you?"
Dr. K:     "Sure."
Dr. Jen:   "Well, see, I have this 30-year-patient who's been having recurrent bronchitis symptoms - mostly bronchospastic coughing - with some persistently decreased peak flows.  I've got her on albuterol and actually bumped her from Flovent to Advair to control her constant coughing.*  I hate to label her as asthma for the first time so late in life, especially without any wheezing, but..."
Dr. K:    (narrowing his eyes) "Is this you?"
Dr. Jen:   *gulp*  "Um, well, ah....yes."
Dr. K:     "Jen, you have asthma."
Dr. Jen:   "No, you're supposed to say, 'Jen, stop being such a typical resident hypochondriac.'"
Dr. K:     "Make an appointment with me, okay?"

I did.

I was not a compliant patient in the beginning; I hated the idea of having a chronic disease, of being "sick."  I evolved from "healthy" to juggling a twice daily inhaler for my lungs, two inhalers for my nose (uncontrolled allergy symptoms worsen asthma, and I've got allergic rhinitis like crazy), a pill for my allergies, and a pill for my asthma.  When Dr. K picked up on my frequent heartburn, he added a twice daily pill for that.*  "Hate" is too gentle of a word for the emotion I felt when I looked at all of those pill bottles and inhalers.

Dr. K was the rare physician's physician.  Through 5 years of treating me, he saw straight through my unimaginative excuses and attempts at self-deprecation.  He picked up on subtle clues in my history and exam - clues that I hadn't even put together myself - that necessitated further evaluation and action.  He gently prodded me to realize that, despite my feeble attempt to convince myself otherwise, I really did need all of that stuff.

I started taking all of my meds as prescribed, and, lo and behold, started to feel like myself again.  I could exercise without getting faint, and I wasn't coughing all over my patients and colleagues.  Do I still hate carrying my albuterol inhaler and spacer with me everywhere I go?  You betcha.  But I have come to accept that I have a chronic disease, and it's not going away.  Dr. K helped me to see that I'd rather kick its butt by taking good care of myself than live in denial and feel miserable.

I tried to thank him before I moved, but he deflected my attempt with kind words about enjoying our time working together.  I like to think that he knew how much he had helped me but was being humble; sometimes, though, I worry that he just was so effortlessly skilled that he didn't recognize just how powerfully he impacted me.

I can only aspire to be as much.

I know; the asthma-reflux connection is controversial.  But try telling that to a pulmonologist.  (And, at least I'm not having heartburn all day any more.)
** In those days, we had lots of samples in our office cabinet.  Since then, most academic institutions refuse samples from Big Pharma, given the evidence that they affect our prescribing habits even when we're aware that they can: (  Looking back, I have to wonder if having those samples available postponed my treatment seeking.

Thursday, December 1, 2011

Doctors need doctors, too

A couple of days ago, I was sitting in a family doctor's office as a patient, waiting to meet my new PCP.

We physicians are notorious for neglecting our own health; a reported 30-50 % of physicians don't even have a PCP.*  I have certainly been guilty of self-treating my own issues, which were sometimes probably reasonable (gluing my small finger laceration instead of going to the ER for a stitch) and were sometimes probably not (self-treating my asthma during residency).

After my friend and colleague suicided,** though, I began reading a lot about physician health, both mental and physical.  I finally approached a pulmonology colleague about my worsening asthma symptoms and got myself to a PCP for some admittedly overdue health maintenance.  Ever since, I have been haranguing the residents I work with about their own health, urging each to have a PCP to call his/her own.

So, there I was, following my own advice, waiting to meet my new PCP in this new town.  And, I was nervous.  Very nervous, truth be told.  Would he be nice?  Competent?  Somewhat close to on time? Weirded out that I'm a family doc, too?  Family docs can be fairly harsh critics of other family docs when they're the patient, after all.

As I sat there, I began thinking about all of the new patients I've seen since arriving here.  Maybe they sat in our waiting room wondering about me with similar apprehensions.  Did I allay their fears?  Most of them have been quite gracious and welcoming to their newcomer family doc.  I resolve to be less family-doc-critic and more gracious-patient when I meet my new doc.

He turned out to be quite kind, highly competent, and very respectful.  And, yes, I behaved myself, thank you very much.  :)  I walked out of his office pleased with the encounter and satisfied that my health is in good hands in this new city.

I hope I've succeeded in allaying my new patients' fears as well.
** see post date 11-15-11

Wednesday, November 23, 2011

Doing "nothing" is still something

I've been struck lately by how often I don't do what my patients are hoping I'll do.  A few examples:
  1. Anyone with <10 days of common cold symptoms (patient wish: antibiotics)
  2. Young, healthy people with chest pain, a normal exam and EKG, and a whole lot of anxiety (patient wish: more heart testing)
  3. Middle-aged men with no risk factors terrified of prostate cancer because a friend was recently diagnosed (patient wish: PSA test)

For those three scenarios, here's why I wouldn't follow my patient's wishes:
  1. Antibiotics do not help viral cold symptoms to be less intense or resolve faster.  They do contribute to a lot of antibiotic resistance, though, making it harder for us to treat legitimate bacterial infections.
  2. If I am confident that the patient is not having a heart attack (low pre-test probability), then testing is just unnecessary expense.  Not to mention that no test is perfect, and the risk of a false positive (meaning showing there was a heart attack when there wasn't), can lead to a whole lot more unnecessary and progressively risky testing and interventions.
  3. Unfortunately, the PSA blood test to screen for prostate cancer is just inaccurate; again, a false positive screen can lead to unnecessary biopsies (which, gents, can occasionally cause impotence and incontinence.  I'll wager that's a high price to pay for a false positive screening test).
Despite our robust knowledge base of medical evidence, the temptation to go ahead and do that something* anyway can be very strong when a distraught patient is sitting across from you.  Some of the hardest patient situations for doctors to navigate are the ones when we choose not to intervene, even though we could (albeit with an intervention that goes against our best judgment).

I was taught what I call "the Balint principle" by a mentor: I, the physician myself, am the most powerful thing I can give to my patients.**  My positive regard, along with my attitude of caring and diligence for them, importantly affects their well-being.  I have learned that exploring patients' concerns and fears related to their issue is terribly important, and I am transparent with them regarding my thought process about why I don't believe their desired intervention is necessary.

So, even when I do nothing, I still do something.  I listen.  I share.  I verbalize and demonstrate my caring.  And, when after our conversation we still fundamentally disagree, I respect their viewpoint and offer them the opportunity to get a second opinion.

After all, as physicians, we always have something to offer - even if that something is just us.

* I can't resist: "Do something!"
** For more on Drs. Balint: ,

Tuesday, November 15, 2011

"The human side of physician suicide"

The title of today's post is also the title of an American Medical Association (AMA) webinar I'm participating in tomorrow afternoon.

I wish that I didn't have a reason to participate in this webinar, but a few years ago I lost a friend and physician colleague to suicide.  I wrote about my grief and anger in a piece that The Annals of Family Medicine was kind enough to publish.  I submitted what started out as just a personal journal entry to the Annals hoping to provoke change in the medical community's treatment of depression among its own. The Annals editors wisely encouraged me to add some research into my personal narrative, and thus I learned a lot about mental illness in physicians along the way.

The whole piece is available below,* but to sum up: physicians historically have stigmatized other physicians who can't keep up with the demands of our profession. For most of the US medical system's history, a psychiatric diagnosis - even when appropriately treated - had to be reported to state medical boards, who could rescind a medical license on that issue alone.  (This process still happens in some states today.)  This stigma and threat of license loss often keeps physicians with mental health issues from seeking care.  Even worse, physician mental illness has been a taboo topic in the medical community - not discussed, rarely researched, and certainly not actively combated.  Thankfully, these attitudes are beginning to thaw, but we still have a long way to go.

I had no idea what would follow from that one published narrative.  I have been tapped as an "expert" on this subject a few times, now most recently for this webinar tomorrow afternoon.  Perhaps most heartbreakingly, though, I continue to receive e-mails every few months from grieving friends/spouses/colleagues who stumble upon my article.  Their e-mails are heavy with despair and guilt, and responding to them always reopens my own old wounds.

I was quite gratified to learn that the AMA is working to break the silence on this important issue.  Indeed, the AMA president this year has made physician mental health one of his top priorities.(1) The timing couldn't have been better; with decreasing reimbursement, higher patient volumes, and increased bureaucracy, today's physicians are under an unprecedented amount of stress. (2)

Tomorrow's webinar is the third and final in the series.  Here's the link to register (it's free):

And, here's the link with the prior webinars in the series:

Please consider tuning in tomorrow afternoon; the webinars are also all being catalogued and can be listened to later if you're working or otherwise occupied tomorrow.  It's time to stop the silence and work together to care for each other as we do for our patients.

Our fallen colleagues deserve no less.

Wednesday, November 9, 2011

What next?

Similar to my prior boss, my new program director (P.D.) meets annually with each faculty member to provide a performance review and discuss goals for the upcoming year.  My appointment with her is only a few weeks away, and I need to come prepared with my short- and long-term goals.

I don't need no stinkin' goals...

The unpredictability of life, which brings both unexpected opportunities (cross-posted on KevinMD?  cool!) and challenges (leaving my last job, for starters), just feels too powerful to control.  I could never have predicted the highlights of my career to date; they happened not because I carefully plotted out intricate plans but because I indulged an interest and threw my heart into it, heedless of the consequences.

I am also an acknowledged detail and results-oriented person.*  I'm not good at thinking abstractly or looking at multiple pieces of a big picture simultaneously. Goal-setting feels like trying to do the impossible - corral the infinite complexities and possibilities of life into some semblance of order.  I'm happy with keeping my bed made and my desk neat.**

In this new position, though, I already feel myself running a bit adrift.  This program is in the midst of a lot of growth, and  I'm at risk of being pulled into fulfilling needs that don't align with my interests.  I know that I'll have to do some things here that I don't love, just as I did in my old program; every workplace has its unpleasant yet necessary tasks, and getting them done needs to be a team sport.  

It seems the only way to balance their needs and my interests (*sigh*) is to discipline myself to set some stinkin' goals, but I'm going to do it my way.  I'm going to prioritize my time toward activities that stoke the fire in my soul.  I'm going to focus on specific, doable targets.  And I'm not going to set 10-year goals - who knows what will happen in 10 years?  

I'm confident that if I follow my passions, opportunities will have materialized by then that I couldn't possibly have imagined.

* For you Myers-Briggs fans, I'm a definite ISTJ:
** There are zero pieces of paper on my work desk.  Zero.  I've been told it's an illness.  ;)

Wednesday, November 2, 2011


"Hello, my name is Jen, and I'm a sleep addict."

Okay, that's a bit of hyperbole, but those who know me well will testify to my lifelong love of sleep.

When I was a kid on Christmas morning, my siblings would try to wake me to go look at presents.  I always grunted at them to "go away;" after all, the presents would still be there after the sun made its appearance.

The thought of staying up all night studying or working on a paper remains incredibly distasteful to me, so in high school, college, and grad school I was one of those annoying students who plotted out study and work plans far in advance to avoid such a scenario.

The first "all-nighter" I ever pulled was in medical school on a third-year rotation call.  I knew that interrupted sleep was a given in a medical career, but I didn't realize until I had to do it how hard it was (for me, anyway).

I learned along the way that my devotion to sleep is a bit of an aberration, at least among docs; while my residency classmates were guzzling coffee on post-call Saturday mornings to attack the weekend with their freedom, I was crawling into bed with a sleep mask to block the sunlight escaping through my bedroom blinds. Their gentle teasing about my need to rest would echo in my mind as I drifted off into that deep, dreamless sleep of the over-tired.

As an attending, I still dread that awful beep-beep-beep-beep of the pager in the middle of the night.   I don't wake easily (my alarm clock's snooze button is rickety with overuse), and I hate being jerked awake.  To be of any use to the residents who page me, I have to crawl out of my bed, lumber into another room, and snap on a bright light before picking up the phone.

I accept this sacrifice as a career necessity; after all, patients don't only get sick between 6 am and 10 pm, and the residents I work with depend on me to guide them through their nocturnal adventures.  I am not trying to escape the responsibilities of being an academic family doc.  To be honest, part of me wishes that I was tougher, that the sleep interruptions didn't bother me so much.

The other part of me, though, wishes that sleep had a little more respect.

Wednesday, October 26, 2011

Getting to know you

Learning how to function effectively in a system vastly different than the one I left has quickly proven to be a challenge.  This office is still on paper until next summer, and handling a bulky paper chart feels awkward and slow to me after years with an electronic system.  I need help completing my billing, getting patients to consultants, even finding a drinking fountain.  If I'm honest with myself, though, none of those details are the hardest part about working in a new office.

I'm ashamed to admit it, but I really miss being surrounded by people who know me well and respect me.  They're going to need some time here to make up their minds about me, and rightfully so.  But I didn't realize until now, until I left where I had been for so long, just how much that liking meant to me.  It made me feel safe to be myself, that it was okay if I wasn't perfect.

Now, I feel like I'm one mistake away from being perceived as incompetent, or one clipped response away from being thought of as unkind.  Of course, the other side of the equation is my job.  To get to know my new teammates.  To understand their joys and their motivations.  I guess we just have a lot to learn about each other.

So, I'll go first.  I've been married for about a year-and-a-half, and, no, we don't have any kids (though my husband did inherit two aging, yet still delightfully mischievous, step-cats).  My mom's father was a Lutheran minister and my mom is an organist.  Dad is a mathematician; his father was a pharmacist and owned a drug store in Grand Rapids.

Yes, at 5'11" you may describe me as "tall" which, to me, equals "hard to find clothes that fit."  I was a field hockey goalie in high school, and I was in the Women's Glee Club at college.  It can take me a while to feel comfortable around new people, but I can also be a bit of a ham once I do.  I'm an efficient worker who likes to find reasons to laugh in the free spaces of the day.

I will pour my heart and soul into caring for your patients.  You've known them a lot longer than me, so I'll need your help to understand them.  I will respect the talents and experience that you bring.  I will also work tirelessly to help grow your residents into self-sufficient family practitioners who are unafraid to care deeply for their patients while remaining lifelong learners.  But enough about me.

How about you?

Monday, October 17, 2011

"Mrs. Dr." part 2

In my last post, I shared the story of how I settled on keeping my maiden name after getting married.

By no means, though, have I always been satisfied with that decision.

Firstly, I don't like imagining a future child having to explain about Mom and Dad's different last names.  Will school officials look at that child's information form and assume that we're divorced?

I also get fatigued of correcting the people I can (new acquaintances) and mutely accepting the people I can't (mostly older family).  Certainly at work, I never have an issue.  And, let's face it, I spend more time at work than not.  Outside of work, though, it feels like I am constantly rubbing against the grain of social acceptability and convention.  As much as I hate to admit it, some secret part of me just doesn't like being "different."  The last name thing is certainly a marker for my non-traditional-self.*

More distressingly, my husband and I were touring a Revolutionary War graveyard in Philadelphia last year.  I looked at the gravestones of husbands and wives, solidly lying side-by-side, and realized the potential future implications of our decision.

"What if, after we both die, people don't realize we were married because our last names are different?"

My husband, in his usual implacable way, didn't seem too concerned, but I continued to silently wonder.  What if some descendant of ours gets confused while researching the family's genealogy?  I worry that we're one missing marriage license away from one of us being irrevocably obliterated from our families' historical records.

My husband's serenity, however, reminds me that our marriage isn't about some future record.  It's not about appeasing social convention or living up to other people's expectation of what we "should" be.  Our marriage is ultimately only about us, as we are in the here and now.  About our decisions, our struggles, and our joys - about the day to day reality of juggling careers and the rest of life.  It's time for me to let tomorrow worry about itself.**

We've got today to live.

* see post dated 1-9-11 re: baby and bridal showers...
** Matthew 6:34

Friday, October 14, 2011

"Mrs. Dr." part 1

My husband was the first of us to get his driver's license in our new state.  He came home from the DMV with a sticky note that had a list on it.

"I told them that my wife still had to come in, so they wrote down everything you need to bring when you come.  I'm just not sure why they would want you to bring our marriage license, though."

I didn't have to look at the list to answer his question.  "It's because they assumed I changed my name when we got married."

A reasonable assumption to make.  A recent (admittedly non-scientific) survey showed that only 8% of American women choose to keep their maiden name after they get married; those who do tend to be older when they get married, highly educated, and "are more likely to work in medicine, the arts, or entertainment" (1).  Hmmm....check, check, and check.

Another 6% decide to hyphenate.  A second poll showed that 70% of women think women should have to change their last name when they marry.  (2)

I didn't expect to get married for most of my life.  Something about that overly ambitious yes-I-need-sleep-more-than-hanging-out-late-with-your-inane-friends-on-a-weeknight just didn't seem too appealing to potential dates and mates.  I was not willing to give up the profession I felt called to, so I just went ahead and told myself I would be happy as a single woman.*

Then I graduated from medical school, and then residency, and then started to make a name for myself in the family medicine academic community.  I told myself that, if I ever did get married, I'd want to keep my name if my husband would agree.  If a future husband were to feel strongly about me changing my name, however, I would be willing to change it; I freely acknowledge that my reasons (then and now) for keeping my name revolve mostly around convenience and professional identity.

Obviously, though, I did get married.  Not long after my husband proposed to me, I asked him if he wanted me to change my name.

It was a short conversation.  It made sense to him that I'd keep my name, seeing as how we're both physicians, and especially since we're in the same specialty.  Neither of us consider ourselves as being "less married" for having different last names.   Isn't marriage about more than names, anyway? (3)

In the medical world, our decision is pretty common.  My medical friends asked me the usual question that follows a female colleague's engagement announcement: "Are you changing your name?"  Some married female doctors use their maiden name professionally and their married name elsewhere.  I always knew, though, that I couldn't live under two identities.  So, "Jennifer Middleton" I remained.

I admit to getting a little frustrated when people assume that I changed my name.  Physician or not, 14% seems to be a large enough percentage to justify the courtesy of asking a married woman how she wishes to be addressed.  The other 86% probably won't mind.

I have had some second thoughts, though.  Stay tuned for part 2...

* Which, for the record, I firmly believe I would have been.  Marriage is full of many joyful things, but it is certainly no panacea of happiness, either.  I firmly reject the idea that it is impossible to live a fulfilled and happy life without being married.

Wednesday, October 12, 2011

It's about the run

I remember well my final run at my favorite park in our old city just three weeks ago.  The air was warm and the trees were rustling in the breeze as I jogged my well-loved loop.  I didn't want to have to leave that park for the final time.  Would I find someplace to run in my new city that was as as zen-inducing as that leafy, peaceful park?

I knew that it was time to move on, but I didn't want to leave my familiar job either.  As much as I could intellectualize about the worthy reasons to go, some tenacious part of me balked at having to start over.  What kind of a doctor would I be in a new place?  Maybe I relied too much on the systems and people around me.  Maybe getting plopped into a new spot would reveal my inadequacies.  After all, I had spent the entire eight years of my post-medical school career in one place.

Leave we did, though, and here I am in my new job.  Everything is unfamiliar, and I am humbled by having to relearn workflows and cultures.  I still get lost in this office and our hospital across the street, though I certainly appreciate the gracious ways my new co-workers are assisting me.

My skills and experience are taking on new meaning here, and I'm coming to realize that my identity and purpose wasn't as tied to my former office and program as I had feared.  I brought my knowledge and personality with me, after all.

Last week, I pulled my running shoes out of a moving box and headed out into our new neighborhood for a jog.  The neat sidewalks and flat topography are definitely different from my old city's feel, but as I trundled down the streets my feet moved just as they always had.  The sky was wide and flat before me, clouds lazily ambling along.  Children were playing in driveways surrounded by trees bursting with a million different shades of oranges, reds, and yellows.  After the run, I experienced the same gentle burst of euphoria afterwards that I always had before.

I'm relieved to discover that I am more than the place that I left.  My skills belong to me, regardless of the context I'm in.  My enjoyment from running wasn't ultimately about the park, it was about the run itself.  My job satisfaction wasn't ultimately about the place, it was about the work I was doing.

No matter where I go, I'm still a family doc.

Sunday, September 11, 2011

Where were you?

Ten years ago today, I was a third-year medical student on my gastroenterology rotation.

The GI attending I worked with was a super nice guy.  He liked to listen to news radio while doing his morning scopes, so we were in the lab for what seemed to be another day of colons when the news radio program was interrupted.

The first World Trade Center tower had been struck.

Sad and strange, we all thought.  But we got back into work for the next hour or so until the next report came.  Tower two: hit.  The radio commentators were noting the unusualness of this "coincidence."

"It's an attack," said one of the nurses instantly.  A horrible feeling sunk in as I realized that she had to be right.

The rest of the day was a blur.  We still had to finish all of the scopes in the morning, and then it was a busy afternoon of hospital consults and an ERCP (the first one I had seen).  My attending and I heard chatter during the day as more details emerged, but the service was busy and we didn't make time to stop.

It was only as I drove away from the hospital that evening, listening to the news reports, that all of the pieces fit together for me.  And, it was only after flicking the t.v. on when I got home that I saw the images for the first time.  One plane, then another.  One crumbling tower, then another.  The Pentagon, a field in rural Pennsylvania, both on fire.

Looking back, I admire my attending tremendously.  He had a job to do, patients who needed care, and he delivered it.  He didn't let the events of the day impact his care of those patients.  Sure, we picked up snippets of what was happening throughout the day.  But the rest of that hospital continued doing its job; we all had to save our grief and fear for later so that we could get the tasks of now accomplished.

We all have circumstances where we must store difficult, heart-breaking things deep inside of us for a time.  Those who stare routinely at violence and death - medical personnel, cops, fire fighters, soldiers - especially must learn to file away some emotion to do the work that must be done.  It's a difficult task, to lock away those feelings, yet the more difficult task is to not neglect to process them later on.  I salute the professionals who continue to make the choice to face terrible sights day after day to serve others.  May you all find peace in the tremendous good that you do.

May we never forget the power of that good in the face of so much evil ten years ago.

Monday, August 15, 2011

Separate lives and split personalities

I was at church yesterday when I got a tap on the shoulder from behind me.

"I can't see exactly what's happening, but it looks like someone's not well over there."  She gestured over to the opposite side of the church, where one of the ushers was assisting an elderly man hunched over in his pew.

So, up I got.  He was ashen-faced, and I helped the usher propel him out of his pew and out the side door.  We led him into the pastor's office and laid him on the couch.

"What happened?"  With a mild shake of the hand, he pulled a neatly typed medication list out of his wallet.  Recent coronary bypass, took his beta blocker and long-acting nitrate as usual this am, but felt a some chest pain and popped a nitro and a vicodin about an hour before the service.  "Nearly passed out" as we all sat down for the sermon. I had one of the ushers get our first aid kit, and I checked his vitals.  His blood pressure was low, as was his pulse.  He probably just got presyncopal from too many blood-pressure-dropping meds, but the chest pain made me nervous.

"What should we do?" asked the small collection of ushers clustered around us.  I had them call 911, and EMS transported the gentleman to the emergency room.  (He ruled out for a heart attack and was discharged this morning.  No more mixing nitro and vicodin!)

I certainly didn't do anything yesterday in church that any other doc wouldn't have done, but I got to do it in front of people who don't know that side of me.  My church friends and acquaintances know that I am a doctor, but they don't know much about the specifics of my days at work.

Being in the medical field is almost like living two separate lives.  The people I work every day with don't really "get" the part of me that likes to write and perform musical theater.  And, my family and non-medical friends certainly don't "get" the medical stuff that I do at work.  Each group of people knows only one facet of who I am, and although I understand why it is that way, I am also a little sad that no one really knows me as a whole and complete human being.

My church friends got to see a tiny glimpse of my professional self yesterday morning, and, in so doing, maybe had the chance to know me on a deeper level.  I think that's why I find these out-of-office/hospital experiences so rejuvenating - they allow me to be my whole self, even if just for a few moments.  I suspect that this divide exists for other people in other professions as well, but I don't know how similiar it is to medicine.  Heck, I don't even know if other doctors have similar musings about medicine and life.

I just know that I wish it could be different for me.

Thursday, August 11, 2011

The same look

It's been a hectic few weeks, with no time to even think about blogging.  But, we've closed on our new house, I'm finally transitioning over work projects here, and the Singing Pen is glad to be back at the keyboard.

I spent most of my free time last week addressing letters to my patients that announce my out-of-state move and imminent departure.  I handwrote every name in the "Dear" line and signed each one individually, so it took a while.  I recognize that I performed this act entirely for myself; it was my opportunity to pause and reflect, if even for just a moment, about my relationship with each patient and family.

But the letters are starting to arrive at homes, and my patients are starting to arrive for their final appointments to say goodbye.  I care for a diverse group - poor urban dwellers and university professors, young transplants to the area and four generation families, white and African American and Iraqi and Vietnamese.  Yet, despite their many differences, each of my patients has been wearing the same expression when our eyes first meet for these appointments.

Their chins point toward the ground, slightly, and their eyes look up at me, daring me to confirm the letters' truth.  Accusations of abandonment are clearly evident in their wrinkled foreheads, and their downturned lower lips hint at the sadness of a severed bond.  The slight pinch of their noses display unease, perhaps, with the unknown regarding their next doctor.  They offer no words to me, waiting instead for me to speak first.

"So you got my letter," I usually say.  I reassure them about their new family doctor here and share my joy in our relationship and sadness in leaving.  They wish me well and thank me for my care over the years.  On and on these encounters repeat themselves , hour after hour and day after day.  I accept this process as a necessary component of my departure.

But every one rips another small piece out of my heart. 

Tuesday, July 12, 2011

Why does GME matter?

Today the medical blogosphere abounds with posts about #SaveGME. 

As a family medicine residency educator, I have to admit that it feels a bit awkward to write about this issue.  I can see how readers might perceive it as rather self-serving, since GME funding is responsible for a significant portion of my salary.  I wonder if other residency educators share my reticence and the reason behind it.  Many people want a smaller, balanced federal budget, but nobody wants their particular piece of the pie cut.

But I am grateful to Mike Sevilla for challenging us to think about this issue, because it really is about more than my job and the jobs of other family medicine teachers.  It's about more than ensuring that the specialty of Family Medicine survives and thrives, and it's about more than making sure that we have enough family doctors for now and the future.

It's about wellness - the wellness of individuals, families, communities, and our nation.  Most medical specialties focus on some body part or system.  Family doctors look instead at the big picture, using both medical knowledge and biopsychosocial training to look at our patients as whole human beings.

This Family Medicine systems approach extends beyond our individual patients.  Because family doctors are wired to think about all of the environmental factors and life choices that affect health, we are better equipped than any other specialty to think about community and population health. 

I recently posted about Dr. Starfield's research findings regarding primary care; at the risk of over-generalizing an impressive lifetime of work, her findings unequivocally demonstrate that primary care helps people to live longer for less cost.  Too many specialists per capita, on the other hand, equals shorter lives and more expensive health care.

Our nation needs a robust primary care infrastructure.  We need primary care leadership to guide local and national decision making related to health - and, let's face it, just about every policy decision relates back to health somehow. 

This point is where we circle back to needing family doctors - and the teachers who train them.  We can't grow those family doctor leaders if we don't train them as family doctors first.  If we don't have a new generation of family doctors waiting in the wings, then our current docs won't get involved in advocacy - they'll be too overwhelmed dealing with the primary care shortage that already exists.

If the health of your family, your community, and your nation is important to you, I urge you to learn more about this issue and make your voice heard.  Dr. Sevilla's post for today ( is a great place to start.

#Save GME.  The future of our nation's health depends upon it.

Thursday, June 30, 2011

As sand falls through the hourglass...

It's June 30, and another academic year is coming to a close for thousands of residents across the U.S. 

This time of year has fascinated me since my residency days.  Certainly, most programs have graduation events for their senior residents, but they are typically earlier in the month of June.  So, June 30 itself comes and goes with little recognition.  Sure, hugs and handshakes may be traded and "congrats!" will be shared, but the patients still need care, the work still needs to be done.  In those small moments of talking with patients and making decisions, writing orders and checking up on labs, the significance of this last day is easily forgotten.  The end of the day inexorably comes, pagers are turned in, sign-out given - and, just like that, it's over.

I suppose I'm especially contemplative this year as my last day nears as well.  Sure, I've had my "last day" as a resident and fellow here, but I always knew I was coming back.  Now, I'm preparing to leave for good.  At each stage of my life, I've always wondered ahead to what the next milestone will be like - and my final exit from this hospital is looming.

I caught a rerun of the series finale of "Scrubs" this past weekend.  J.D. wants his last day at Sacred Heart to be special, magical almost, yet he knows that the deep meaning of his years there can't be captured in the few available moments of what is just another busy day for everyone else.

As the episode ends and J.D. prepares to leave for the final time, he fantasizes that he is walking through the hallway to the exit doors flanked by staff members, colleagues, and patients he's known during his time there.  Of course, he ultimately exits through the doors alone, but he's taking the lessons and camaraderie of those relationships from his time at Sacred Heart with him.

I'll walk out of the door of my hospital in a few months, and I'll have no more fanfare than today's residents when they leave their residency training sites later today.  I am confident that none of us will let the anticlimactic nature of those final minutes take away from the rich experiences and memories that we have accumulated.

A part of me, though, wishes that J.D.'s fantasy could be true for all of us.

Tuesday, June 28, 2011

9 things I shouldn't have stopped doing

So I was standing in line at the grocery store over the weekend when I saw the following article advertised on the cover of Cosmopolitan:

"50 Things You Shouldn't Have Stopped Doing"

Now, I admit that I read my last Cosmo over a decade ago.  I also suspect that the 50 "things" on their list are rather different than where my thoughts started to go after seeing that phrase. 

Residency education is a curious field.  For my type A-ish personality, a main source of stress is knowing that my "to do" list will never be finished.  I follow up on my patients' labs, fill out their paperwork, and field their phone calls and e-mails just like private practice family docs.  (And my hat is truly off to those of you who do that for 100% of your week and not my measly 30%!)  My academic duties* are the ones that truly consume me, though, and with our move out-of-state little more than three months away, I have a ton of projects to wrap up and duties to hand off.

So between that work and the effort of finding a new house, selling our current house, getting a new state license, and applying for privileges in a new hospital, here are a few things that I shouldn't have stopped doing:

Connecting with in-town and out-of-town friends
Listening to (and loudly singing along with) Broadway showtunes
Driving with the windows open and the radio off
Eating at the dinner table
Reading for fun
Sleeping in on the weekends
Going on dates with my husband
I am quite grateful to that article headline for the self-reflection it prompted.  In the four days since, I have managed to run twice, sleep in once, and even go to the park with my husband.  I'm not fooling myself - life won't really achieve any level of normalcy until we're settled in to our new home in our new state with our new jobs - but at least I'm starting to feel like myself again.

So, what's on your list?

* For those of you who are curious or looking for a great way to induce sleep tonight, here's the list of my current responsibilities that I recently compiled for my program director:

Maintenance of own patient panel: 3 sessions/week

Outpatient precepting
Tues & Thurs afternoons
“Fill in” prn (average 2-4 additional sessions/month)

Inpatient teaching service supervision 4-6 weeks/year
Assistant Medical Director of our outpatient office

Coordinator of weekly “Core Content Series” educational time for residents
Ongoing support for outpatient EHR issues
2 Hospital committees
Management of Point of Care device policy for incoming residents

6 EHR Committees
Medical Decision Making course – assistant session leader
Provide feedback to presenters (and support fellows doing so) when lead faculty not available
Assist lead faculty with developing annual curriculum and canon of articles
Faculty Development Fellowship activities
Presentations: advanced precepting skills, precepting with the EHR, presentation skills, writing skills
Support for fellows at regional and national meeting
1-on-1 preceptor training
Support for residents’ presentations at regional and national meetings

Faculty advisor for 7 residents - biannual reports on & quarterly meetings with each advisee
Coordination and team-teaching of weekly tech curriculum
                        Tuesday afternoon FHC tours
Fill in for interviews as needed
AAFP National Conference in KC
FMEC (formerly NE STFM Region) Conference

Tuesday, June 14, 2011

The underrepresentation of primary care

Like many in the FM world, I was saddened to learn yesterday of Dr. Barbara Starfield's death.  Also, like many in the FM world, I was disheartened to see the scant amount of coverage in the medical news sphere about her passing.

Dr. Mike Sevilla had a great post on this same subject yesterday.  He included links to Dr. Starfield's research and an embedded video of her receiving the FMEC Lifetime Achievement Award:

I left a small comment at the bottom of Dr. Sevilla's post that I'd like to expand upon.  It's baffled me for years that Dr. Starfield's findings have not enjoyed greater publicity in the lay press.  With all of the national chatter about heath care costs, why hasn't the media broadcasted the message of primary care's cost-saving and health-prolonging benefits?

Her findings are pretty darn news-worthy:
US counties with more primary care docs per capita have lower mortality rates; counties with more specialists per capita, well, don't.  (1) 
Inappropriate medical interventions (unnecessary medications and procedures) - which are more likely to be done by specialists - are actually the 3rd leading cause of death in the US.  (2) 
After controlling for other factors, Canada's better health equality (compared to the US) is likely due to its robust primary care infrastructure.  (3)
Instead of sharing these critically important findings, however, the lay press focuses on health scares (cell phones!  tanning!  meningitis!) and picking apart the the Affordable Care Act (you'll have to pay for insurance!).  Sure, occasionally a primary care story makes the national media rounds (remember Dr. Gawande's NY Times article about Dr. Jeff Brenner? [4]).  Apparently, though, robust primary care doesn't sell ad space as well as bedlam and furor.

Perhaps we're not selling primary care correctly; after all, primary care is downright fascinating.  Yesterday I treated a child's asthma exacerbation, buddy taped a middle-aged broken toe, and juggled an older patient's insulin doses.  Today I could see a septic newborn, someone with a psychotic break, even someone having a heart attack.

And infinitely more interesting than the diseases are the people.  The professor whose trigger finger is keeping her from her enormous garden.  The college athlete whose football talent made him the first in his family to get past high school.  The 40-year-old who became a mother (again) and a grandmother in the same week.

These sometimes brave, sometimes witty, and always genuine human beings pepper our careers with depth and meaning.  Their stories happen countless times every day in primary care offices across the country.  I applaud the primary care bloggers out there (some of whom are featured in that column to the right of these words) who are fearlessly sharing our stories and perspective with a wider audience.

What might happen to our national sentiments about health care if the lay press started picking up on those stories?

Wednesday, June 8, 2011

From doctor to daughter...and back again

I suspect that most physicians have, at some point in their training, heard the following phrase:

"Treat the patient like she's your mother."
Or, this variation: "Remember that every patient is somebody's mother."

Well, this past week, it was my mother.

I always thought that these phrases were intended to remind us of the individual humanity of our patients.  Especially on busy and overwhelming days, it's not difficult for Mrs. Smith to become "the COPD-er in 627."  These phrases also seem to echo the golden rule ("do unto others' mothers as you'd like others to do unto your mother").

But after sleeping on the floor of my mother's hospital room for four nights and interacting with her many caregivers, these phrases have a new hollowness for me.  I'm sorry, but even the most conscientious, compassionate, and caring health professionals cannot care for my mother as if she was their mother.  She's not.

My mother's caregivers were kind, thoughtful, and available, and the medical care that she received was excellent.  (Believe me, as a physician-daughter I was watching!)   But her family supported her emotional and physical needs in ways that no one outside of her family network could.

Yes, our patients deserve humane and compassionate care.  Yes, it's important for us to get to know our patients.  And, yes, all of the patients under my care are somebody else's mother, father, daughter, son - but they aren't mine.  I see now that pretending that they are is utterly impossible and that being the best doctor I can be is good enough.  I will leave the daughter-ing to the daughters and the mother-ing to the mothers.

After all, doctor-ing is hard enough on its own.

Wednesday, May 25, 2011

Change-induced anhedonia

So, the Singing Pen has been struggling to get motivated lately.  Despite Larry Bauer's excellent guest post nearly two weeks ago, I just can't seem to get a post beyond a few sentences these days.  I am beginning to see that my disinterest with academic and family medicine topics is due to an overriding issue that, until now, it has not been appropriate for me to broadly share.

I have announced my resignation at my current position, as my husband and I will be moving out-of-state in September.  The decision to leave - and choosing new jobs - has been an agonizing process for us.

I've always been an efficient and energetic worker, but lately I am finding myself distractable and fidgety.  Keeping my focus to precept or teach is a chore.  I have little interest in following Twitter.  I've barely posted on Facebook and am isolating myself from my friends.

I am experiencing both grief and anxiety.  Grief for what will be lost, anxiety for what is to come.  I am already mourning the loss of day-to-day interactions with colleagues, learners, and staff here.  I worry if I will I fit in at this new place.  I don't want to start over again building relationships.

To be fair, I am also excited about our future.  I genuinely enjoyed meeting my future colleagues, who are an amazing and inspiring group.  It'll be fun to house hunt again.  The city is beautiful and the right size - with the right amount to do - for us.  We will be much closer to our families, whom we've both been feeling the pull to be closer to lately.  I am confident that the decision to relocate is the right one for us.

But this place, where I survived residency, conquered fellowship, and took my first fledgling attending steps, feels like home to me.  With the perspective of the interview trail behind me, I see now that my identity has been too tightly enmeshed with my current position.  My self-view is dominated by this program and the work that I do here.  Perhaps I have cared too much, been too invested in this place.  Regardless, the time has clearly come for me to leave the nest.

I just wish that I wasn't afraid to fly.

Thursday, May 12, 2011

GUEST POST: The Founders of Family Medicine

Larry Bauer, the CEO of the Family Medicine Education Consortium, distributed this essay to the FMEC Board (full disclosure: I am a member-at-large on the board) and others in his network earlier in the week.  The founders of Family Medicine dreamed big; more than just creating another specialty, they wanted to fundamentally change how medicine is practiced.

He has graciously granted me permission to share his essay here.  I'll share my thoughts in a follow-up post.

Courtesy of Larry Bauer, MSW, MEd:
The Dreams of the Founders of Family Medicine
As Family Practice emerged from the field of General Practice, it is important to realize that many in and out of medicine told the founders they would not succeed. The cynics believed that the dominant forces in medicine were too entrenched and there were too many societal forces working against the idea of a generalist renaissance in medicine. “Real” medicine of the future aspired to something more worthy. Real medicine involved care of hospitalized patients and was informed by the scientific and technological advances associated with sub-specialty medicine. Anyone could care for the people “out there”. But the founders dreamed big, bold dreams; they were a determined and visionary group.
They dreamed of a cadre of talented and competent Family Physicians that would serve the people in all the communities of our nation. The rich, the poor and all in between in rural, urban and suburban communities; all needed access to a Family Physician. They believed that the practitioners in this specialty would focus on the needs of their patients and communities and would protect people from the medical industrial complex as much as possible
They dreamed that a new academic specialty would emerge whose core would focus on issues surrounding patient management and the care of the whole person in their community.  They believed that medical education was moribund and harmful and in need of a compassionate and thoughtful revitalization.
For the founders, the biomedical model was inadequate. They believed that it is not possible to be effective as a physician without understanding the contextual issues that influence a person’s life. The biopsychosocial model, the power inherent in relationships and the abilities and skills involved in creating facilitative relationships needed to be integrated into medical education, practice and scholarship.
They believed that medicine was a profession that involved more than a technical set of skills and a high income. They accepted the responsibility of caring for the whole person; mind, body and soul.
They believed that the practice of medicine required team work among the medical and helping professionals and that the patient was to be an active partner in the care process. In fact, it is the patient’s goals and agendas that drive the healing process. 
They believed that lifelong learning and the need to continuously upgrade one’s knowledge and skills was critical to the practice of medicine.
They dreamed of generations of leaders who would rise to take their places and extend their efforts.
They believed that Family Medicine was more than another group of medical practitioners. Family Medicine should serve a transformative agenda that changed the academic medical centers and health systems so that they would better serve the people and communities.
They were willing to bring other generalist colleagues to their ranks. They respected the pediatricians especially who wanted to contribute to Family Medicine’s early development. They sought a relationship with psychiatry and mental health professionals. They had a comfortable relationship with the general surgeons and all their colleagues who respected the value of a generalist practitioner.

Thursday, May 5, 2011

Shout out to my "tweeps"

So, the Singing Pen is returned from my trip to the Society of Teachers of Family Medicine annual meeting in New Orleans last week. 

This particular STFM meeting felt very different to me than the others I've attended in the past, and I have to credit Twitter.  The social media "tweeps" there live-tweeted a lot of the conference, which as a relative newbie on Twitter I had never experienced before.

It was just incredibly cool!  By following the #STFM hashtag, I picked up all kinds of great ideas from sessions I didn't even attend.  I also got a kick out of contributing live tweets from the sessions I was attending; in one session, someone tweeted me a question in response.  I approached the presenter at the end of the session to find out the answer for him.

After introducing myself, I stated that I had been live-tweeting her session and that someone had tweeted me a question to ask.  The presenter very kindly provided an answer (which I tweeted back out) and then said, "that's a new one for me!"  She had never been asked a question about her presentation by someone not physically in the audience before.

Now, lest you cry out in horror "how did you ever pay attention and tweet at the same time?," let me reassure you.  Tweeting during the sessions was basically like taking notes, except that I was sending out my notes, real time, to people not at the session (and even not at the conference).  I can access everything I typed out easily, and so I have a record of all of the ideas - and my responses to them - from every session I attended.  Plus I have the ideas - and responses - of every other session live-tweeted there by others.

Conferences will never be the same for me again.  When I was responsible for sharing the content I was hearing about, I became much more mentally engaged with the presentations I was attending.  The constant Twitter hum of dialogue about goings-on made me feel much more connected to the conference as a whole.

And, last but far from least, this introvert also crept out of her shell and met some of the folks I follow on Twitter who were there.  They are an amazing, thoughtful, and fun group that I am now privileged to know both in person and in the Twitterverse.

Looking for a way to get more plugged into your next conference?  Tweet away!

(For a great wrap-up of the STFM Annual Meeting, check out Dr. Mike Sevilla's Family Medicine Rocks blog:

Tuesday, May 3, 2011

Making the most out of conferences

Last week, I ranted a bit about the imperfect conditions of most conference settings.  Today, I'd like to suggest ways around some of those issues; I'll also throw in some general tips about how to have a great conference experience.

1. Dress for success
Presenting at your conference?  Pack a suit or other professional clothing.  You want to look like a pro, so be sure to bring along that suit or outfit that makes you feel like a presenting rock star.

For the non-presenting times, typically business casual will do.  Conferences are networking opportunities, and I wouldn't want to meet a potential future employer or colleague while looking super-casual.  Remember, first impressions are powerful!

In addition, indoor conference sites are usually super-air-conditioned, so be sure to dress in layers, especially if your conference venue is in a warm place.

2. Ask for a low floor
When reserving your hotel room, ask for a low floor.  In my experience, you will typically get the floor or two right above the conference center, which will make moving back and forth between conference and your room an elevator-less experience.  In a bigger hotel, you may still need the elevator, but you'll be the first off and the last on, leading to a much shorter ride.

3. Get creative with space
Empty/unused conference rooms make great, quiet workspaces.  If there's nothing going on in the evening or early morning in the smaller conference rooms, I will sometimes hunker down in one and get a little work done.

4. Bring your business cards - and keep 'em on you at all times.  Make sure that they have your e-mail, Twitter name, Facebook page, Linked In profile, and/or whatever else you want on them.

5. Pack with organization
Packing cubes, collapsible shelves - there are all kinds of nifty packing systems out there that help to keep your things organized and relatively unwrinkled.

6. Plan each day the night before
Which sessions will you attend?  If you're presenting, when will you head over to set up?  When might be a good time to take a break (and you'll probably need one at some point)?  Tap into your experienced colleagues, too, about which presenters are a "don't miss."

7. Don't ask, don't get
I learned this phrase at the conference I was just at, and it will stick with me.  Don't be afraid to ask for free internet or fitness center access - if you ask nicely, you may be surprised how often you will get it!  One of the attendees that I met last week asked for free internet at this hotel, was initially told "no," asked again nicely, and then they capitulated.

Please feel free to comment on your own experiences, and happy conference-ing!

Friday, April 29, 2011

Traveler's wish list

I travel fairly frequently to conferences for our residency program - to help with resident recruitment, to learn, to present, and to support our residents and fellows who are presenting.  In the last five years, I have traveled to such events an average of four times a year.  I have seen a lot of hotels and conference rooms!

This week, I have the privilege of attending another meeting, but my experience, yet again, could be so much better with only a few minor changes by the hotel.

Here are my top gripes of hotels in no particular order - hotel business owners, are you listening?

1. "Nickel and diming"
Conference hotels are not inexpensive.  Even with the "conference rate," one night typically costs in excess of $200.  Yet, if I want WiFi in the quiet privacy of my room, it almost always costs extra.  If I want to use the work-out facility, it also usually costs extra.

2. Exhaust-ed
Why don't most hotel bathrooms have exhaust fans?  A 10-minute shower steams up the entire bathroom and usually the rest of the hotel room to boot.

3. Insufficient work space
I am sharing my room with a colleague to lower the cost to our program.  But there is only one small desk in this room.  Hotel "business centers" typically consist of 2-4 antique computers suitable for little more than printing out boarding passes, with little extra work space.

4.  Mega-air conditioning.
Even the men in short sleeves can be heard complaining about the temperature at these meetings.  Even if it's 90 degrees outside, does it need to be a meat locker inside?

5. Crappy hangers - or not enough hangers.
Eight hangers for two people for five days?  And trying to hang pressed clothes onto a hanger that you can't remove from the closet rod?  Please.

6. Slooooow elevators.
'Nuff said.

But, don't despair conference attendees.  Stay tuned for tips on how to overcome these obstacles and have a great conference experience!

Monday, April 25, 2011

When assumpions become "facts"

The post for this week was supposed to be a rant against rising drug costs.  Here's how far I got before realizing that I should get some specific data to make my points more convincing:

Back rounding with the inpatient resident service recently and, yet, again, I was irritated by the widespread use of Zofran in our hospital.

Let's back up.  Zofran's been around since 1991 in the US.  Researchers developed it to treat chemotherapy-induced nausea and vomiting.  Because Zofran rarely causes any untoward side effects, it became a popular anti-emetic for non-chemo related nausea and vomiting as well.

The older antiemetics, Compazine (prochlorperazine) and Phenergan (promethazine), work great for most nausea and vomiting but didn't perform as well for chemotherapy-related n/v.   They also can also infrequently cause unpleasant extrapyramidal side effects (acute dystonic reactions, akathisia, tardive dyskinesia) along with, rarely, cardiac arrhythmias.

When I was a resident, I remember well the experienced Emergency Department physicians that I rotated with.  "I don't know what's wrong with good old Compazine," one would frequently say.  "Sure, it can rarely cause bad stuff.  But most of the time it doesn't.  And it's a helluva lot cheaper."
So, I e-mailed some of the pharmacists that work at our hospital, asking for the costs of one dose of each of those three medicines.  All I needed to finish off the post was to plug in those costs and let my readers be outraged at the widespread use of the extremely expensive Zofran versus its cheaper counterparts.  Another couple of lines about cost-control in medicine and - voila! - post completed.

Except that my friendly pharmacists e-mailed back to let me know that all three of those meds cost about the same; one IV dose of any of them costs between $1.00 to $1.50.


(Insert picture of me eating humble pie here.)

So much for the rest of that post!

Turns out what I thought was "fact" was totally incorrect.  Yet I have been railing against the spread of Zofran use in our hospital since starting as an attending there nearly three years ago. 

"We, as physicians, are largely responsible for rising health care costs," my diatribe to the residents would begin.  "Why are we using Zofran, an expensive drug for cancer-induced nausea, for an otherwise healthy 25-year-old with viral gastroenteritis?  There are less expensive options that are reasonable to use, yet somehow Zofran has become the de facto antiemetic around here!"

Shame on me, for treating my assumptions as facts.  When Zofran first came out, it probably was more expensive.  But that was several years ago, and I never bothered to update my thinking.  We do that frequently in medicine - tout our biases and thinking as irrefutable facts - but those examples can wait for another day.  For now, I need a glass of milk to wash down this humble pie. 

And one dose of Zofran for the post-pie dyspepsia, please.

Monday, April 18, 2011

Why aren't more docs on Twitter?

I was precepting last week at our busiest outpatient site.  One of the residents there is very interested in all things technology and we got to talking about the iPad.  Knowing that he uses Twitter, I told him about some of the neat ideas I had recently seen there about the use of tablets in patient care. 

The preceptor room is a public place, and it's pretty easy to be overheard.  This resident and I were only about two minutes into this conversation when the comments began to fly from the other residents - and the other preceptor - in the room.

"Twitter?  That's just for celebrities."
"Twitter's a waste of time."
"Twitter's just to make yourself feel important."

Even more discouraging was that my attempts to explain the positives of Twitter - networking, idea sharing, collegial support - were brushed away.

"I have enough things to check every day already with e-mail, Facebook, and texts."
"Twitter is all self-serving.  Does anybody really care what you have to say?"

I have heard these types of comments across all ages and generations.  I have heard them at conferences, among the faculty I work with, in the monthly book group I attend.  Twitter is decidedly not mainstream in medicine, at least not in the circles I travel in.

I have seen and read countless articles, ideas, and opinions that I wouldn't have found without Twitter.  Yes, it takes a little time to find good people to follow, and it then takes a little time to actually follow them.  But the pay-off in new ideas and inspired thinking is marvelous - far better than the same amount of time on Facebook or an RSS reader.

For the most part, physicians are notoriously late adopters of new ideas.  Health systems had to mandate EHRs to get most physicians to use them.  In an age of e-mail and text messages, most of our offices remind people of appointments with a phone call.   Heck, I was a Twitter skeptic a year ago.

Interestingly, though, once docs have these new technologies, they're equally reluctant to change back.  (You should have heard the uproar here the last time the computers went down.  "Write my notes...on paper?!?")  Which leads me to wonder if some of these Twitter bashers would be still so negative if they were actually Twitter users.  So, how about it, Twitter detractors - why not give it a try?

I dare you.

Wednesday, April 13, 2011

Family Medicine - the antidote to the common sense blues

Reading through the responses to my post from yesterday, I realized that Steph and webhill were taking the conversation in a new direction.* I'd like to expand on their very valid points.

These kind responders shared similar stories of supposedly "abnormal" health metrics that initiated some sort of protocol, even when it didn't make an ounce of sense.  Two healthy newborns subjected to unnecessary (and costly) interventions.  Another similar experience to mine regarding "low" blood pressure.

You don't need any medical knowledge, really, to figure out that Steph's baby didn't need to go to the NICU, or that webhill's didn't need formula.  Heck, you don't need a day of medical or nursing school to know that the resident's patient from yesterday's code story was perfectly fine.

So, what is happening in nursing and medical school that strips that common sense away?  Certainly the first two years of medical school focus on learning the minutiae of how the body works - biochemistry, anatomy, etc.  All that time spent memorizing neurotransmitters and cell receptor signals then yields to being ready to respond instantly to your attending's pimping in the third and fourth years about the coagulation cascade or your patient's colonoscopy biopsy results from eight years ago.

The partialists** especially seemed to delight in these details when I was a medical student.  Frankly, it seemed then - and it seems now - that those practitioners best able to see the whole picture were - and are - the family docs.  Perhaps it's because they are the only ones truly taught to think about the patient as a whole being and not a collection of organ systems and biometrics.

Of course, we need our partialists.  They provide important and complimentary skill sets to ours.  But a family doctor should be at the center of every patient's care.

More family medicine as an antidote to the common sense blues?  It couldn't hurt.

* I genuinely appreciate every one of you readers who, at some point, has taken the time to continue the conversation by responding to one of my posts.  You all are the ones who truly keep things interesting around here.  :)
** Please see entry from 3-1-11 for more about the "partialist" label.

Tuesday, April 12, 2011

Shifting the bell curve

The nurse at my doctor's office was checking my blood pressure last week when the following conversation ensued:

Nurse: (trying not to look worried) Um, have you ever had low blood pressure before?
Me:  No.  I've always had normal blood pressure.
Nurse: (now not hiding worry) Well, I'm getting 100/70 for you.
Me:  Yep.  Perfectly normal.

One of the residents today was telling me about a code he attended in the hospital yesterday.  The code was called for hypotension (dangerously low blood pressure).  The resident rushed into the room to find the patient sitting calmly, eating his breakfast.  The nurse informed the resident that the patient's blood pressure was 90/60.

My intention here is not to lambaste nurses.  They are merely following their protocols and experience.  The larger question, I think, is when did reasonable blood pressures become "low"?  Is it just because most of the blood pressures that nurses (and docs, for that matter) see are elevated? 

I can't separate the word "normal" from the picture of a bell curve in my head.  And I have to wonder if the bell curve for "normal" blood pressures isn't starting to shift toward the right.

I don't like the complacency toward a new norm that these events portend.  How can we convince our patients that their blood pressures are too high when the bell curve of normalcy has shifted?  I have started using the word "healthy" to describe desirable blood pressures instead of "normal."

Because, sadly, normal doesn't seem to be healthy anymore.