Crossing the First Threshold

An Excerpt from a Work-in-Progress

All the third-year medical students were paired up. Debbi and I were happy to be working together. We had become good friends in the past two years. Debbi had managed to survive the grueling academic schedule despite a 90-minute commute each way, despite caring for a child while pregnant with her second. She delivered her second son during the summer break, then nursed him while sitting through third year classes. Some of our classmates had no appreciation for what she was going through.

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Once during second year, the tape for note service came out inaudible. The person responsible for note service that day tried to get Debbi to give up her personal tape of the lecture. Listening to tapes while driving was how she managed to stay afloat. Our classmate was asking her to give up her life jacket. When she refused, he tried to guilt her into it by saying it was for “the good of the class.” (more…)

Happiness: Finding the Way

You may have noticed that I haven’t posted in a while. I made a public commitment to post monthly, and a private commitment to post twice a month. I succeeded for three months, then I fell off my schedule.

Labyrinth Heart

v_rybakov/123RF Stock Photo

I could say that life got in the way. That’s believable for a busy clinician. The truth is, I simply lost my way. I didn’t have a depression, it was more of a dis-ease. I felt out of balance, and not just my regular lack of work-life balance. (more…)

You Don’t Know You’re Grieving

(Until You Do)

This week, our hospital again held Schwartz Center Rounds. The topic was organ donation, and we discussed the families of the donors, the pride in the legacy of passing life onto others through death. We discussed the unbearable waiting for the transplant recipients and their families, waiting that ended with either grief or gratitude, sometimes both.

copyright: gdolgikh/123rf Stock Photo

copyright: gdolgikh/123rf Stock Photo

The panel was made up of both Gift of Life and hospital employees, all with very personal stories to tell. (more…)

The Step-by-Step Guide to Saying No

Essentialism, Part 2

Here’s a paradox. People actually respect you more if you say no to them. Well, actually they respect the fact that you know your goals and are willing to fight for the resources to accomplish them.

Loss as Opportunity

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I’m at a phase in my career when I want to cut back on clinical hours, but I want to continue helping patients and their caregivers. I want to expand my influence in a train-the-trainer sort of way, to leverage my experience beyond my hour-to-hour, appointment-to-appointment life. Clinicians and caregivers, people who take care of people in both professional and non-professional capacities, can benefit from what I’ve learned. (more…)

How Coyote Taught Me a Lesson

The Clinician's Anti-Burnout Manifesto

If you’ve done any reading about healthcare recently, you know that medical culture can lead to burnout. You know that depression and suicides among physicians are rising at alarming rates. You know that work-life balance is practically nonexistent and self-care is almost impossible.


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In the last 10 years, doctors-in-training have been enabled and empowered to limit their work hours, to limit the number of patients they see. Older doctors scoff, saying the younger ones are being babied, that they’ll never be well-trained if they don’t continue at the same grueling pace that physicians have always worked at. The macho culture is long and deep. Recent changes in the system, especially electronic medical records (EMR’s) have exacerbated the crisis by decreasing flexibility and autonomy for all clinicians. (more…)

Lose Track of Time

Chronos versus Kairos

This past Monday, I had the privilege of helping to facilitate Schwartz Center Rounds at my hospital. In 1995, Kenneth B. Schwartz, at age 40, was diagnosed with metastatic lung cancer. Before he died, he set up a foundation at Massachusetts General Hospital to strengthen the compassionate bond between patients and their caregivers. Today, about 375 hospital organizations in the US and Canada are members of the Schwartz Center along with 120 in the UK.

The heart has its own time.

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The member organizations of the Schwartz Center participate in rounds to discuss cases in a way they are usually not discussed. Instead of talking about what was done or not done in a case, members of the healthcare team talk about how the case made them feel. In the words of one rounds participant, “Rounds are an opportunity for dialogue that doesn’t happen anywhere else in the hospital.” (more…)

Just Say No, Gracefully

Essentialism: The Book Summary

Here’s the main thing, the essence. People become the victims of their own success, because if they do something well, they get asked to do more and more. This ultimately dilutes the original greatness. If everything is a priority, then nothing is a priority. You can spend your life moving one step in 360 different directions, with the net result of never moving at all, or you can move 360 steps in a single direction and make a significant contribution.

Just Say No

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That’s the main message of a book by Greg McKeown titled Essentialism: The Disciplined Pursuit of Less. I’m now consciously trying to incorporate this philosophy into my life. In my next post, I’ll talk about my personal experiences with this process, but for today, here are the main concepts. The basic process is to Explore, Eliminate, and then Execute effortlessly.


To be an Essentialist (as opposed to a Non-Essentialist) you start with the ability to choose. A Non-Essentialist’s motivation is “I Have To,” while an Essentialist says “I Choose To.” Subtle reframing of life’s priorities as choices undoes the feeling of entrapment and loss of control. (more…)

IT and Sympathy

There has always been a disconnect for practitioners between doing what they do and then writing about it in the patient’s chart. This was true when we had paper charts, and the advent of EHR (electronic health records) has made the separation even wider. When my notes were on paper, written longhand, I often got compliments from other practitioners. They found my notes to be clear, concise, and helpful in orienting them to what my plan was, and to what was going on with the patient.

Stethoscope and Keyboard

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Paper Versus Electronic Note

E-notes tend to be long because they’re inclusive. Prior history, problem list, vital signs, fluid intake, labs, x-ray reports, medication lists can all easily be pulled into a note. This is precisely what makes them so unfocused and useless for emphasizing what the note writer thinks is really important. (more…)

When Your Client Nods and Smiles

but has no clue what you just said

I recently saw a patient for the first time who was referred to me for evaluation and treatment of chronic hepatitis C. In my urban clinic, this is something that happens quite frequently, at least a few times a week. In general I prefer that the referring physician do only the hepatitis C antibody test and a viral load (level of virus in the blood) to confirm that the patient has gone on to develop chronic infection. In a small percentage, 10-15% of the time, patients will spontaneously clear the infection without treatment, so they will have positive antibody but the virus will not be detected in their blood.

Copyright nito500/123RF Stock Photo

Copyright nito500/123RF Stock Photo

In an attempt to be helpful, the referring physician in this case had done a more extensive work up, and the patient was surprised and a bit dismayed to find out she needed more testing. I carefully explained the additional tests that I needed and the ones that would need to be repeated. I needed to make sure the results were recent enough for her insurance to approve the expensive but effective new treatments for hepatitis C. After my explanation, she agreed to do the lab work and the ultrasound of her liver. We scheduled a three-week follow up to review the results. (more…)

Palliative Care Is Like Memory Foam

A Cushiony Extra Layer of Support

Yesterday, a patient told me that “nothing was being done” to treat the cancer that had been diagnosed four months ago. I pulled up the most recent oncology note in the computer and read the details to him. Of course the oncologist had told him everything I was telling him. Why did the patient not know that he had a follow-up appointment scheduled? The clue was at the end of the note. “Patient is requesting Valium. Will defer to his primary care provider.” A complicated diagnosis and treatment plan was carefully laid out to a patient who was too anxious to hear any of it.

Copyright: Maxym/123RF Stock Photo

Copyright: Maxym/123RF Stock Photo

This was the first time I met this patient in Palliative Care clinic, and the most obvious thing about him, the point that dominated the resident’s presentation, was the patient’s anxiety. Apparently the resident was so impressed by the anxiety, that he neglected to tell me some pertinent medical history before I entered the room. Thinking back on it, I wonder whether the resident had the misguided notion that Palliative Care is only about psychosocial issues, not about practicing good clinical medicine. I hope he learned from my example as I looked up the summary of the hospitalization from last August and all of the oncology notes.

When residents come to Palliative Care clinic for the first time, I tell them it’s no different from practicing Internal Medicine, but with a slightly different focus. I use the acronym GAPS to help them remember what to focus on in addition to the standard medical assessment. (more…)