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. http://bit.ly/uhpDfi
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.  http://bit.ly/uYFRBm
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).  http://bit.ly/qcsI5X

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: http://www.youtube.com/watch?v=SMTDQZzQMKk "Do something!"
** For more on Drs. Balint:    http://www.balintinternational.com/downloads/Balint_in_a_Nutshell.pdf , http://americanbalintsociety.org/, http://www.jfponline.com/Pages.asp?AID=9167&issue=December_2010&UID=

"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): https://cc.readytalk.com/cc/s/showReg?udc=fxqwubd3v67r

And, here's the link with the prior webinars in the series:
http://www.ama-assn.org/ama/pub/meded/2011-november/2011-november-pd.shtml

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.

* http://www.annfammed.org/content/6/3/267.full
(1) http://www.ama-assn.org/ama/pub/ama-president-blog.page?plckController=Blog&plckBlogPage=BlogViewPost&UID=0b90b13b-8074-42d2-be9a-5d263dc8c945&plckPostId=Blog:0b90b13b-8074-42d2-be9a-5d263dc8c945Post:57cd846b-50bb-4003-bd99-eecd074555a7&plckScript=blogScript&plckElementId=blogDest
(2) http://www.ncbi.nlm.nih.gov/pubmed/20851643; http://www.kevinmd.com/blog/2010/10/ama-physician-health-priority.html

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.

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: http://www.123test.com/ISTJ-personality-type/

** There are zero pieces of paper on my work desk.  Zero.  I've been told it's an illness.  ;)

Zzzzzzz....

"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.