It Takes a Pit Crew

The Race To Treat HIV Disease

Several years ago, Atul Gawande spoke to the graduates of Harvard Medical School. His address was published in the New Yorker under the title of “Cowboys and Pit Crews”.  In his articulate way, Dr. Gawande described the necessary cultural transition in the way health care teams operate and cooperate. His article came to mind as I was preparing to speak at the World AIDS Day Service of Remembrance this past December 1st. I was tasked with giving statistics on the current situation of HIV in Atlantic County, but I began with a poem. I wrote this back when AIDS was much different than it is today.

copyright: michaeljung/123rf stock photo

copyright: michaeljung/123rf stock photo

Your Choice

I happen to be there when you’re admitted.
My job is to keep you alive at any cost.
Lucky for you that I have experience
and I’m really good at diagnosing

the opportunistic diseases of AIDS.
So when you have the bad luck
to have a rare pneumonia
and a virus attacking your eyes, (more…)

The Secret to Dealing With “Difficult” Patients

Simple But Not Easy

Work life in health care is filled with stress. There’s time stress, lack-of-sleep stress, role stress, and computer stress. One of the most challenging stresses for caregiver professions, though, is people stress. Every student at her medical school interview will say she wants to be a doctor to help people. That remains true at some level for all doctors, but sometimes we have to help people who are trying to control or manipulate us, who are making demands on our limited time, who are being defensive or hostile, who don’t follow our good advice, or who don’t seem to care about us and our feelings. There’s no way to avoid these people, and it’s unprofessional to be rude or hostile or aggressive in return.

Copyright: Bela Hoche/123rf

Copyright: Bela Hoche/123rf

So, what’s a healthier way to deal with unpleasant encounters? Several years ago at a Humanities in Medicine retreat, I wrote about this encounter. I was called to do a consult for a patient who was in isolation for MRSA. When I got to the floor and asked the nurse about the patient, she just rolled her eyes.

I pulled on my yellow isolation gown and then my blue gloves, left first, then right, always in the same order. The patient sat with arms crossed answering my questions with mono-syllables. I sat on the fake leather sofa across from him. Experience and intuition prompted me to ask him, “Do you know why you’re in isolation?” “No,” he said. “They told me I have MRSA, but I don’t know what that is.” (more…)

Don’t Be a Cooked Frog!

Legend has it that a frog will jump out if placed into hot water, but if you raise the temperature gradually it will stay until it’s cooked. This is an apt analogy for how older physicians currently view their jobs. If we were to jump from college graduation into our current high-stress, low-control jobs, many of us would jump right out. Yet, our current jobs have evolved gradually over the last 20 to 30 years, and we manage to stay in them. The key to not getting cooked is to prevent and treat burnout as it arises.

Photo Credit: Yotrak Butda/123RF Stock Photo

Photo Credit: Yotrak Butda/123RF Stock Photo

I recently came across a useful way of organizing my thoughts on my personal struggle against burnout. I found it on Dike Drummond’s website (TheHappyMD.com). He calls it “The Burnout Prevention Matrix,” and it’s readily available in exchange for opting in with your email address.

I had been searching for some time for a framework that doesn’t put the entire onus for health on physicians and nurses. Dike’s matrix includes responsibility for organizations to reduce stress and energy drains on their employees, to increase recharge activities and efficiency for their employees.
Organizations will hone in on the word “efficiency” here, I’m guessing, because increased efficiency can lead to higher revenues, but what about the need for employees to have time to recharge? (more…)

Teaching the Skill of Empathy: The Legacy of J. Andrew Billings, MD

The whole Palliative Care community was saddened to hear of the death of Dr. Andy Billings. You can find his obituary here, and you can learn more about him in this article from the New York Times on “How Doctors Die.” I learned of his death just hours before I was scheduled to present a journal club to the Internal Medicine residents I teach. As synchronicity would have it, the articles* I was presenting were the three that Dr. Billings had written on how to run family meetings in the ICU. I felt that Dr. Billings’ spirit was guiding me as I asked the residents to role play and then debrief a difficult ICU family meeting scenario.

Photo Credit: hxdbzxy/123RF

Photo Credit: hxdbzxy/123RF

I would never have had the courage to try something like this had I not watched Dr. Billings lead a group of physicians through the same process back in 2010. I came away from that seminar with a clear vision of what a family meeting entails, how it’s a division of expertise. The health care team and the family meet and share what they know. The physician is the expert on the clinical circumstances, but the family is the expert on the patient, on who he was and on what he would say if he could speak for himself. It was a simple but elegant way to describe the concept of substituted judgment. Ideally, if there’s no written advance directive, the family doesn’t have to make decisions for the patient. They merely have to express the known wishes of the patient. It may seem like a subtle difference, but it takes a lot of the stress and guilt away when making life-or-death decisions. (more…)

Does a Physician Have to Be Disruptive to Be a Bully?

The physician leader literature is full of references to “the disruptive physician,” the one who openly humiliates and bullies other providers on the health care team. Often, one thinks of an older male physician denigrating a younger female nurse. Lack of open communication in health care, though, with team members failing to speak up on behalf of a patient, may deal with a subtler, more pervasive type of intimidation.

Photo Credit: Robert Churchill

Photo Credit: Robert Churchill

 

Here’s something that happened in my hospital. An ICU “family meeting” was called to try to determine whether a patient should proceed with with having a percutaneous endogastric (PEG) tube placed. The patient had lived an astounding 69 years with Down Syndrome, but had not been spared from its complications, most notably early onset dementia. She was fully dependent on others and bed-bound by the time she came to our hospital.

The geriatric literature is clear: patients with end stage dementia should not have a PEG tube placed because the burdens outweigh the meager benefits. (more…)

Cold Hands, Warm Heart

For me, physical symptoms are a clue to something I don’t want to know about myself. If I have a sore throat, I wonder if there’s something I need to say that isn’t being said. If I get a neck pain, I might attribute it to stress or a virus, but I also think, “Who or what is being a pain in the neck to me?” The pain in my right shoulder stumped me. I asked myself, “Am I shouldering too much responsibility?” One of my employees was making everyone around her unhappy. She was the puppy in the practice, charming at first, but very disruptive when any form of self-discipline was required, even after three years of training. The office dynamics were beyond the help of a dog whisperer. I eventually made the painful but right decision to let her go, but the shoulder pain persisted. I began to think the pain was a protective armor that no longer served me, but I couldn’t let go of it. That’s when I turned to my friend Ed for help.

Copyright: sifotography / 123RF Stock Photo

Copyright: sifotography / 123RF Stock Photo

The hallway at Seashore Healing Arts Center was chilly, but the space heater was on in Ed’s massage room. I sat against the wall in a metal-framed chair with an aqua vinyl seat. Ed sat across from me, holding his tape recorder. He always recorded his intuitive sessions. He asked me why I was there before he closed his eyes to center. A few minutes later, he turned on the tape recorder. First, he listed the muscles which were involved. He knows I’m a doctor, so he can be technical: anterior deltoid, subscapularis, pectoralis, rhomboid. Then he delved deeper. (more…)

Follow Your Passion

I am in the process, as many of you are, of helping to launch a young man into successful adulthood. One thing my husband and I decided a long time ago was to try to nurture our son’s true interests rather than force a path on him based on financial prospects. This has turned out to be wiser than we knew. Who could have predicted 20 years ago, when our son was 2, that his interest in computer games was just as likely to lead to a successful career than if he had been interested in business, or law, or even medicine? Of course, nurturing interests has its downside, too. Over the years, our home has been filled with multiple musical instruments: alto sax, tenor sax, EWI (electronic wind instrument), keyboards, synthesizers, guitar, drum set, erhu ( a Chinese bowed-string instrument), sitar, not to mention the electronic game controller “instruments”  for Rock Band and Guitar Hero (multiple versions of each). The point is, had we limited him, or if he had limited himself out of fear for the future, rather than his loves in the present, he wouldn’t be happy now or in the future.

In my parting comments as former president of the medical staff, I continued some of the threads I began in previous comments. In my first article, “Culture Medium,” I shared some of my own journey through adversity, in the forms of both physical illness and burnout and fatigue. I talked about the importance of self-care. My healing antidotes included mindfulness, music, and especially reading and writing poetry. (more…)

Infinite Hope

“We must accept finite disappointment, but never lose infinite hope.” –Martin Luther King, Jr.

“Just as the tumultuous chaos of a thunderstorm brings a nurturing rain that allows life to flourish, so too in human affairs, times of advancement are preceded by times of disorder. Success comes to those who can weather the storm.” –I Ching

 

These are the quotes I used to end my inaugural speech for my second year as Medical Staff President at AtlantiCare. That night, I talked about the common use of symbols of light to accompany winter holidays. These holidays fall near the Winter Solstice, the longest, darkest night of the year, but the dark is lighted by stars, candles, and flashing colored bulbs. Medicine as an industry is going through a time of radical transformation, and at times, that can feel like a long, dark night. We continue to take steps every day on life paths we have chosen, and there’s little time to consider whether that path still leads to the destination we envisioned.

The twinkling-light part, though, is that we have traveling companions on that road. In our collective physician community, we have all the strength, wisdom, knowledge, experience (and table-tennis skills) any of us will need. The question, though, is how do we overcome our fragmentation, how do we break down the walls of the silos that keep us apart in order to share all that wisdom and strength? (more…)

Culture Medium

 

No, my first blog post is not going to be a discussion of sheep’s blood agar, even if I am an Infectious Disease doctor. The title is a reference to my theme for the years when I was Medical Staff President. My theme was cultural change. In picking a theme, I followed in the tradition of my predecessors who had chosen themes of patient safety and improved inter-provider communication. Physician culture is an unwritten contract between physicians and their hospital system that governs physician behavior. Cultural change means examining where we are now in contrast to where we need to be. My future blog posts will deal with the specifics of change through improving end-of-life communication, through narrative medicine and reflective writing, through improving resilience and self-care by incorporating the humanities into ongoing medical education. But the first thing for me to address in this inaugural blog is, “How did I get here?”

I once took a writing workshop in creative nonfiction. The first exercise was to describe how I got there. Ten minutes. Go! I scribbled furiously for ten minutes. Several exercises and a long weekend later, I had my first publishable piece of creative nonfiction. So, when I was asked to contribute a presidential welcome to the Medical Staff newsletter, that phrase popped into my head: “How the heck did I get here?” (more…)

Welcome to My WordPress Blog!

Here’s where you can find my monthly updates on what’s going on at the intersection of poetry, infectious disease specialty practice, and palliative medicine, with a little bit of mindfulness practice thrown in.

My target audience includes both lay community members and other physicians who are interested in

  • honest end-of-life communication
  • narrative medicine and reflective writing
  • humanities in medical education
  • increased resilience in medical providers
  • self-care for physicians and residents

I look forward to connecting with you!