Transcending Quality in Pursuit of Clinical Excellence

This speech was delivered as the keynote address at the 2018 Induction Ceremony for Georgetown University School of Medicine’s 2018 Gold Humanism Honor Society Induction Ceremony. 

Excerpts have been published on:

The Arnold P. Gold Foundation Blog 
Johns Hopkins Medicine’s CLOSLER.ORG

……………..

Good evening. I’m grateful to be standing here, speaking with you. I hold dear to my heart simply being a member of the Gold Humanism Honors Society. Sharing the Spirit of this group with you today is an honor I’ll never forget. So I want to thank Dr. Moore, Dean Mitchell, Dean Kumar, and Dean Heussler for this opportunity.  

I also want to thank those who have come before me here at Georgetown.

People like Dr. Pellegrino, Dr. Knowlan, Dr. Harvey, Dr. Adams, and dozens more.

I am able to share these ideas today because, in their centuries of cumulative practice, they cemented in these walls an unwavering commitment to the art of medicine. A commitment that continues to echo through them today, and one that will do so for years to come.

And to each of you, the 2018 inductees, I hope you take a moment to savor the meaning in being recognized as a Doctor’s Doctor. As someone who embodies what it means to not just treat patients, but to truly care for them. Congratulations.

After all, this is why we chose medicine.

  • To come to know new depths of the human experience.
  • To create meaning at the bedside, in the sacred space between patient and physician.
  • To bear witness to illness and take part in caring for not only the body, but also the soul.

The poet John O’Donohue describes beauty as that in the presence of which we feel more alive. When we experience those moments of patient care in its purest form, they embody just that– beauty. Vibrating through us and instilling a combination of joy and humility and pride and gratitude.

I’ve seen this several times over the last four years.

I’ve watched faculty members like Dr. Murphy deploy delicate words and elegant listening to help an entire family process the painful reality of a quickly aging loved one.

I’ve watched Dr. Moore shift from teacher to caregiver to advocate in a matter of minutes at the HOYA Clinic– in each role, making the people in front of her feel like no one else mattered but them.

I’ve watched Dr. Selden dance among being a friend, a physician, and a confidant, communicating with her patients in ways that showed them just how much she understood the nuanced intersections between their illnesses and their lives.

And I have watched my peers, including many of you, walk into a hospital room and light up a patient’s eyes. I’ve watched your listening ears, your caring hands, and the compassion in your mere presence be medicine in and of themselves.

The unifying factor between each of these moments is what I want to talk to you about today. Excellence.

In a time when there’s a growing emphasis in medicine on the idea of quality, you, as members of the Gold Humanism Honors Society, carry the task of preserving and propagating excellence.

But if we are going to talk about quality and excellence, we must first be very clear about what the two words mean. The writer Seth Godin, taught me quality is a term coined by industrialists like Edwards Deming who pioneered the changes that made Toyotas the reliable cars we know today.

Through his pursuit of quality, Deming made sure that every car ran the same, felt the same, looked the same, sounded the same, and as a result, could be produced as efficiently, affordably, and error-free as possible

In other words, quality means meeting a very clear, predetermined set of rules.

Quality is reproducible and it is scalable, and we see it arising everywhere in medicine.

From quality-improvement projects that develop hospital-wide systems to get antibiotics to critically-ill patients as fast as possible, to quality metrics that hold physicians accountable for making sure each and every diabetic patient has the right blood sugar levels.

And rightly so! If we can make healthcare more affordable, more efficient, and less error prone, we should do it.

But, if we chase only quality to a degree that we lose sight of excellence, we fail our patients.

Because  

It’s the quick wink we exchange with a patient when our team passes by on rounds.

It is noticing the subtle sigh a patient lets out when we tell her we still don’t have the diagnosis, and making the effort to unpack the emotions brewing beneath her stoic surface.

It’s listening more and interrupting less.

It is remembering that the physical exam embodies much more than uncovering diagnostic findings, carrying in it our patient’s trust that we will use our hands to care and comfort.

It’s stepping up to the bedside and into our patients’ worlds and showing up each day grateful for the fact that our they let us see them.

In other words, excellence is challenging yourself to ensure your patients feel just how much you care, day after day after day.

If you find this idea daunting the way I do, I promise you’re already well on your way to manifesting it because you have years of practice being a human.

And that is all this is. Being human.

But, amidst the competing demands of clinical care, humanity, while simple, is not easy.

Unfortunately, the incentives of our healthcare system do not always line up in ways that encourage you to choose emotion over efficiency, compassion over costs.

So, as you chase excellence, you will stumble.I certainly have.

As a third year student, I can remember the first time a patient asked me if he were dying. At 55 years old, he was a few days removed from a big surgery when his liver and his kidneys started to fail. When I saw him early that morning, he had aspirated and was on the cusps of respiratory distress.

Between his labored breaths, he looked at me with wide, bloodshot eyes, and asked, “Am I dying?”

I panicked. I was so scared of offering the wrong response that I didn’t give myself the chance to ask the right questions.

I regurgitated a trite, scripted line about how I didn’t know what would happen, but could assure him we would do everything we could to keep him comfortable. He nodded and we stared at each other for a few seconds before my resident arrived– me, frozen, and our patient, gasping.

He died that night.

For the last two years I’ve thought about all the things I wish I had asked. The fears I wished I had uncovered, the end-of-life priorities we could have honored.

Because, while his words came out as a question, the look on his face told me he knew the answer.

And while my response may have been of fine quality, I missed an opportunity to show him how much I cared.

I am convinced that these sometimes painful reflections are a necessity as they allow us to discover ways we can infuse excellence into a world that sometimes over-prioritizes quality. And when we do, when we move along the spectrum from meeting metrics to going far beyond them, we engage in the art of medicine. For, excellent practitioners like you make meaningful art.

We’ve all heard the classic archetype of the physician as an artist. Toiling away at the bedside and at his desk, blending together science and emotion as he recites professorial axioms about clinical care.

But as the medium changes, so too does the artist. Excellence today is not the same as excellence 50 years ago, because medicine today is not the same as medicine 50 years ago. Where there was once one person– the physician– followed by everyone else, there are now many, all working together. Physicians, NPs , PAs, nurses, social workers, respiratory therapists, patient navigators. And especially, our patients.

We deliver care in teams and we no longer work on the patient, but rather, with the patient.

If excellence lies in the work of finding ways to honestly say, “I hear you. I’m with you. I’ve stepped into your world,” then team-based care, with the patient its center, brings the extra eyes that help us overcome our inherent biases and blind spots– the ones that have alienated and discriminated entire populations for decades.

And since it is easier than ever before to speak up and speak out, we can advocate with our patients with more force and volume by seeking out and elevating the voices too often silenced by systemic injustice within our healthcare system and our society, at large.

 For we have a long way to go in understanding the judgments we cast. And our patients have more to teach us than we will ever get the chance to learn.  

But to benefit from the power and perspective of team-based care, we have to, once again, be human. We need the humility to admit, “I don’t know,” the curiosity to ask, “What do you think?” the courage to speak up and say, “This isn’t right” and the self-awareness to wonder, “Am I supporting those around me as best I can?”

Because, after all, we’re in this together.

Despite the culture of competition amongst medical students, the turf wars that can exist between specialties, or the frustrations that may arise between providers, each and everyone of us is in this because we’ve chosen the journey of making a difference.

So, your final responsibility as members of the Gold Humanism Honors Society is to care for one another the way you care for your patients.

In a time when provider burnout, depression, and suicide continue to rise, we all have a role in breaking the culture of silence that cultivates isolation and shame.

We can lean into the uncomfortable vulnerability of sharing our fears, our failures, and our anxieties. Of swallowing our pride and admitting our fallibility. Of reaching out and saying, “you’re not alone. I know this because I’m feeling that way, too.”

Dancing with these difficult emotions does not require talents or gifts or other worldly skill. It is merely a practice. And if you treat it that way–as a daily ritual– it will change the way you engage with your patients and your peers. 

You will be the person who leaves the lives of those you touch better off.

The physician who ensures your patients always experience the calming comfort of knowing you are there for them as a physician and a person.

Excellence and art will no longer be something you do. Instead, they will become a part of who you are.

With time and effort and practice, each one of you will embody the mission of the Gold Humanism Honors Society and bend the arc of medicine in the compassionate spirit of serving your patients. Neither for acclaim nor accolades, nor awards or prestige, but for the person that brought you to medicine in the first place.

The person Dr. Knowlan put at the forefront of your mind when you first donned your white coat and took the Hippocratic Oath three years ago.

The patient. The patient. The Patient.

Thank you.

The Power of “What Else?”

This article was originally published on the Library of Professional Coaching website. You can read the original HERE

“What else?”

This question, in all of its simplicity, has been the defining theme of my coaching journey, instilling a profound change in the ways I approach relationships with myself, my patients, and my colleagues.

For a young medical student paddling through test after test, lecture after lecture, the concept of “what else?” is foreign. Traditional medical education consists of two, two-year blocks. In the first, students spend their time in classrooms where they learn the requisite medical sciences –  pharmacology, pathology, physiology, and the foundations of human health and disease. During these pre-clinical years before we step full-time onto the hospital floor, life revolves around multiple choice tests, and thus, around finding the answer. There’s no room for “what else?” in the binary world of right and wrong answers. Eventually, after enough tests, students move on – no, we get catapulted – into the clinical years of patient care where, sometimes, there are multiple right answers, and at others, none.

My first experience with coaching came weeks before I would strap into the catapult. I was mulling on a list of insecurities and anxieties about stepping into the nuance, uncertainty, and emotional challenges of patient care. My biggest fear, I explained to my coach, Maggi Cary, was that amidst the academic demands of performing well on my clinical clerkships, where I would try to impress supervising physicians and earn the grades and recommendations necessary for acceptance into competitive residency programs, I would lose sight of the relationships, the patient stories, and the humanity that first called me to medicine.

When Maggi asked how I thought I could keep track of these competing tensions, I gave her my answer, which I thought was the answer.

“I’ll focus on my studies and, if there is time, make sure I keep an eye on how well I feel I’m maintaining empathy and compassion.”

“What else?” she asked.

I stared at her, thinking to myself “There is nothing else . . . that’s just how it is . . . right?”

“I’ll really focus on my studies? . . . and really try to make sure I keep an eye on my empathy and compassion?”

Did I mention the concept of “what else?” was foreign to me?

“Do you mind if I show you something?” Maggi asked, pulling a piece of paper out of her leather portfolio. Over the next 90 minutes, she introduced me to the concept of “Both/And” thinking through Barry Johnson’s Polarity Maps. Polarities focus on managing interdependent pairs and avoiding an endless cycle of swinging to one side or the other, never finding a way to strike the balance just right.

Think about some polarity pairs you may face. Your personal life and your professional life. Prioritizing yourself and prioritizing others. In your business or organization, you may feel the tension between mission and margin, staff satisfaction and customer satisfaction.

In my case, I had fallen into a cycle of Either/Or thinking. I felt I had to choose between traditional medical education, which consists of grades and test scores, or transformational medical education, which consists of the bedside medicine and interpersonal connections I love. Instead, as Maggi helped me see, the optimal solution would never come out of choosing between, but instead, finding ways to leverage both poles.

Whether it’s making career decisions, interpreting social interactions, or crafting the words to best help a patient deal with a life altering diagnosis, my first reaction, especially when heavy emotions are involved, pulls me toward one pole of the polarity pair at the expense of the other. As I’ve learned through working with Maggi, this reflexive response often stems from insecurity, anxiety, or perceived weakness.

Due to my initial concerns entering the clinical years of medical school, I reluctantly felt the need to gravitate towards burying my nose even deeper in my studies, because I felt my test scores and pre-clinical grades would be my Achilles’ heel in earning acceptance to a strong residency program. There were more times, too. When I felt certain a fellow classmate’s comment came from a place of malice rather than jest, it was because I filtered the world through a lens colored with an ongoing fear of being disliked. And when I defaulted to a robotic response after a man on the cusp of respiratory failure asked me if he were dying, it was because I was so concerned with giving the right answer that I didn’t think to better understand the fears underneath his question. As a result, I failed in giving him both a good answer and hisanswer– one that would give him peace in his final hours.

So comes the importance of “what else?” By stopping to consider other options, by choosing to see the situation from another perspective, or by challenging our own subjective interpretation of our day-to-day, we open ourselves to leveraging both poles of interdependent pairs. “What else?” helps us move from Either/Or to Both/And and Either/Or.

If it sounds as though grappling with the concept “Both/And” and “what else?” takes time, it’s because it does. That time is one of the most important dimensions of my coaching experience. As Maggi would sit with me for hours, she would create the space for me to explore the depths of my emotions and the way they intersect with my experiences as a medical student. In the process, she helped me build a habit of thoughtful self-reflection as she modeled the type of curiosity and generous listening I hope to bring to interactions with my patients and peers.

Medicine has undergone a stark transition marked by exponential expansion of not only the biomedical knowledge a physician must maintain, but also the interpersonal and emotional demands a physician must manage. As health care has become a team sport, the historic archetype of the physician toiling away at his desk has grown into one with new responsibilities. Physicians must now be both brilliant thinkers and compassionate leaders, managers, and quarterbacks of patient care. These multiple roles often compete with one another.

How does a physician manage her duties to help the hospital system in which she works minimize costs and ensure profits while honoring the commitment she has made to do everything for the patients in her care?

How does a physician executive wrestle with the need to keep patients safe while also ensuring these safety precautions do not place an undue burden on the already over-flowing expectations of nurses, technicians, and other essential healthcare providers?

How does a physician find ways to also be a spouse, a parent, a friend, and a son or daughter in a field that can sometimes demand everything?

And how does a physician manage all of the above, at the same time, with speed, efficiency, and emotional stability?

By embracing dualities and Both/And thinking. By living at the edges of the needs of the those they serve in their personal and professional lives. By choosing to pause and examine situations from different perspectives. By asking, “what else?” and by recognizing when our fears, our insecurities, and the dark sides of our strengths influence our decisions.

In other words, by taking on a coach’s habits, thought patterns, and behaviors, and deploying them in the moments when our patients, colleagues, and loved ones need us.

Changing our ingrained behaviors takes time and goes against almost all of our inclinations. It took over a year of work to feel somewhat comfortable with “in the moment self-coaching,” where I catch myself falling into the patterns Maggi and I discuss and shape my actions by asking myself the questions she usually does. This will be a lifelong journey for me and I am grateful that I have already started. For, when I finish residency in three or four years, my career will catapult me once more. This time, into a position where my decisions can change the course of a colleague’s career, a family’s experience with the healthcare industry, and a patient’s life.

What if I had never had the chance to explore this material with Maggi? What if I had never learned to ask “what else?”? I worry it would be too late by the time I found myself in high-level leadership roles.

When I met Maggi not even halfway through medical school, the demands of training had already started to groove counterproductive coping strategies. Had this continued for another five years, the cumulative effects could have made reactive, defensive leadership a habit. I may never have embraced active reflection or Both/And thinking. Most importantly, I may have burned out and lost sight of my capacity to keep hold of the relationships, the stories, and the humanity that brought me to medicine in the first place. I may have lost my sense of meaning.

One morning on my surgery clerkship, I went in to visit a patient I had been caring for the last few days. He had recently been told that the surgery he needed to leave the hospital had been postponed, meaning he had spent the last 48 hours in an uncomfortable hospital bed, missing time with his wife and children for nothing. He was upset and frustrated.

As I walked in the room, his abrasive tone caught me off guard. “Are you here to tell me I’m not going home today either? Staying another day?”

I wanted to defend our decision and tell him why it was the right call to postpone his surgery. But, as Maggi has taught me to do, I paused and asked myself if that’s what he was really asking.

“What’s bothering you?” I asked, as I sat down next to his bed. “What else is going on?”

My question disarmed him. His eyebrows relaxed, his shoulders dropped, and his stare lightened.

He was tired, frustrated and felt like he didn’t have much control over what was happening in his medical care. No one was asking him what he thought, only telling him what would happen.

“Deep down, I know it was the right call to hold off on surgery. I appreciate you listening,” he said.

Before I left, he confessed how hungry and sick of hospital food he was. I found his nurse and we snuck him a candy bar. I can still remember that sigh of satisfaction when he took his first bite.

I texted Maggi, bursting with pride about how I had applied her coaching, and she replied, asking, “This is what it’s about, yes?”

“Yup. It is,” I responded. “He feels better. I feel great. And all it took was for me to take a second and ask myself, ‘Does he really want to know only that?’ Just a brief pause before giving a reflexive response. Just enough time to ask myself, ‘what else?’”

As I walked home that evening, I reflected on how coaching had helped me manage the tensions I had previously found unmanageable. But, there was something more. In the process of working with Maggi, in the hours during which she helped me look inside myself, she had taught me being a good doctor, a good leader, and a good person involves challenging our reactions, stepping out from behind the safety of judgment and always being willing to ask, “what else?”

In the process, she made sure I always had the tools to peer beneath the surface of the people I engage with and find the shared humanity that exists within us all. The shared humanity that first brought me to medicine. The shared humanity I was so scared to lose sight of.

Why Digital Healthcare Can Never Replace Doctors

This post was originally published on The Doctor Weighs In

Minutes after Fast Company broadcast Bodega’s mission to put corner stores out of business, Twitter users fired back in defense of the local shops, their employees, and the social anchor they bring to neighborhoods.

Founded by two ex-Google employees, Bodega plans to combine artificial intelligence and machine learning with employee-free vending machines to meet your every last-minute need. Its software’s high-level analytics helps machines predict exactly what local customers will buy, giving each its own customized inventory. Rather than trotting down to your local corner store full of history, character, and family-owned pride, Bodega aspires to have their machines, which will integrate into already existing structures, such as apartment buildings, dorms, offices, and gyms, become your one-stop shop.

While the company seeks to solve the problem of efficiency and convenience, it creates a new one in eliminating the human touch and sense of community central to the customer experience. Advocates for traditional bodegas rave about kind, generous owners, the shop’s role as a financial opportunity for families immigrating to the United States, and most importantly, the personality and warmth each store brings to crowded concrete cities that can swallow our sense of belonging. For some, it’s the only place where you know you will get a friendly “hello”.

Bodega’s valuable lesson for digital health

Public response to Bodega offers a valuable lesson for another industry where traditions rooted in compassionate relationships collide with new economic advantages of artificial intelligence and automation: the digital health movement.

As a graduating medical student and Silicon Valley native, I’ve watched tech start-ups flock to the healthcare space in the same way they have to retail. The first half of 2017 set records for Digital Health, with $3.5B going to 188 different companies. Much of this funding comes on the heels of the hypothesis that machines and artificial intelligence (AI) can replace doctors by making faster and more accurate decisions.

Apps claim to help you diagnose yourself from your couch with just a few simple questions, eliminating long waits in crowded doctor’s offices. IBM’s Watson is supposed to take your oncologist’s job by determining the best cancer treatment for you using data from millions of similar cases. Cutting out time-consuming and error-prone healthcare personnel, Silicon Valley argues, will make healthcare a cheaper, more affordable, and more enjoyable experience for patients.

Are time and money the only currencies worth optimizing?

Like bodegas, healthcare serves customers through meaningful connections that an app or machine can’t offer. While some areas of medicine rely on algorithms and diagnostic trees, they intertwine with the intricacies of humanity in ways that only empathy and compassion can decipher. Medical teams gather and assimilate information through incremental relationship building that best occurs at the bedside, not in front of a robot-staffed LED screen.

The most useful parts of a patient’s case are often the most private, as medical histories weave into our identities and emotions in ways that other personal information never will. Domestic abuse victims don’t reveal why they have bruises up and down their arms to healthcare professionals who fail to make them feel safe and valued. It can take multiple visits for a stoic, elderly man to reveal that he has started to fall at home. It can take even more time for him to come around to using a walker that, in his eyes, signifies the beginning of old age. Patients’ stories tell us that coming to terms with your own mortality after a cancer diagnosis—or determining if your two-year-old is wheezing because of a mild virus, or something worse—feels cold and empty without a hand to hold or an ear to listen.

Before you eviscerate me for being stuck in the dark ages of medicine, let me be clear: I am not a Luddite. I admire and respect the opportunities tech companies bring to healthcare. For example, Sherpaa and the new relationship between Apple and Stanford put information, autonomy, and accessibility in the hands of patients. At the same time, they facilitate patients and providers to engage in the conversations and shared decision-making that embody compassionate, connected care.

Magic occurs when high-tech and high-touch synergize

I think back to watching a physician get a phone call from a patient who was having chest pain. He recently survived a minor cardiac event and now grappled with the lingering concern that any chest discomfort signaled impending doom.

I know it’s scary,” the physician said, “I’m staying on the phone with you. Do you think you can take an EKG the way I showed you in the office last week?

Okay,” the patient agreed through the short choppy breaths that sounded like he was gulping down air.

A few minutes later, he had emailed us a copy of his heart rhythm taken with electrodes that stick to the back of his phone. It was normal. An app or a robot could have told him that. But, it would have precluded the relief in knowing his doctor, the one he trusted with his life, had been there when he needed him.

Magic rises out of these areas where high-tech and high-touch synergize for the sake of patients’ physical, mental, and emotional health. They aren’t a mutually exclusive pair and this isn’t an “either/or” decision to make. We need to leverage both.

A transactional view of the world frames corner stores and doctor’s visits as time wasting problems we can eliminate through the speed and efficiency of digital innovation. A humanistic perspective illuminates the reality that we can’t put a price on relationships and community, and that caring hands and listening ears can be medicine in and of themselves.

Just because we can replace people at the expense of connection doesn’t mean we should.

This post was originally published on The Doctor Weighs In

My Grandpa’s Socks

This post was initially featured on In-Training

Whenever I go to the hospital, I wear my grandpa’s socks. They looked distinguished on an older man, but a little childish on a me, a 25-year-old medical student. I’m okay with that. Feeling like an overdressed kid on Easter helps to balance the overwhelming pressure of becoming a physician.

I still see Pop sitting in a chair with his silver hair that was too strong to fall out during chemo. He’s half smiling, with a slight eyebrow raise. Even just thinking about him, I can smell that nostalgic mixture of moth balls and Polo cologne. While one elbow rests on the armrest, his fingers fiddle with a small scrap of paper he always seemed to have. He has one leg crossed over the other, his pants halfway up his shin to display his timeless socks that match his timeless sweater. They were usually wool, sometimes cashmere, solid or a traditional argyle, in classic shades of navy, maroon and grey. Noticeable, yet subtle, they represent maturity, humility and composure. Pop, like his socks and outfits, always seemed so together. This is the Pop I knew.

Then there’s the other Pop. The one I only heard hushed, whispered stories about. This man is belly up, sprawled out on a diving board. Iron weights dangle off his ankles a few inches above the surface of his backyard pool. As the breeze rustles the tree leaves, the winter sun casts a paltry spotlight on a suicidal alcoholic. My grandpa. Pop.

Pop set high expectations for himself.  He had to be strong, independent, and successful.  He hated the idea of burdening anyone else with his issues, so he swallowed whatever life threw at him. He wanted to be perfect.

With these heavy expectations, Pop, like all of us, had to cope. Opening up or asking for help wasn’t an option; it would have exposed the fact that he couldn’t handle it, whatever “it” was. At first, drinking eased his self-imposed pressure. Eventually, it yanked him into a self-destructive cycle, ripping away the curtain of security that hid his inability to live up to his ivory tower ideals. Unable to meet unrealistic standards, he felt like a failure. Failing, in his eyes, was a waste of life. So, he tried to end his.

Full of pills and alcohol, with weights tied to his legs, he waited on the diving board, hoping to pass out, fall forward, and sink to the bottom of the pool. Luckily, he passed out and flopped backwards.

I don’t just wear Pop’s socks, I wear his demons, too.

Like him, I fear failure. Like him, I want to be perfect. Like him, when faced with high expectations and left to my own devices, I feel the pull towards isolation and the self-destruction. Not wanting to expose my weaknesses or be a burden, my gut tells me to put on a smile, shove down the uncomfortable emotions, and white knuckle through the hard times.

The last time I talked to Pop, he was nearing the end of a steady, but peaceful decline. After overcoming the suicide attempt, a collapsed lung, pancreatic cancer and a heart attack, his body was finally giving out on the last of his nine lives.

As I sludged my way up to lecture, I tried to keep it together. My hood covered my tear streaked face, my silence covered my trembling voice. I walked extra slow, savoring one last chance to get one last lesson.  Today, he opened his textbook on life to the chapter about A Bronx Tale, one of Pop’s favorite movies.

“Jack,” he said, “the saddest thing in life is wasted talent.” My talent, according to Pop, was my potential to become a good doctor.  I would waste that talent if I followed in his footsteps, suppressed my internal struggles and walled myself off from support. Those behaviors, he told me, brought him to the diving board that day. Connecting, stepping out of his own head, and opening up to others helped keep him from going back.

Talking to Pop was like getting the answers to a test you didn’t know you were going to take.

Now, a year later, as I’m trying  to come into my own as a physician, I doubt myself and fear failure everyday. The mental, physical and emotional demands of medicine compound these insecurities in a culture that often refuses to acknowledge they exist.  The high-achieving, overly independent atmosphere pushes students to prop up a pristine, image of strength, competence and unwavering resilience. I wish it was that clean on the inside.

Amidst the long hours, competing demands and big tests, we struggle to find time to pee, let alone process the inner turmoil that comes with grieving families, dying patients and tracking our own fulfilling path in medicine.  On top of that, none of us want to admit we can’t handle it. All the good doctors seem to be emotional fortresses. Most of our classmates, too, at least on the outside.  No one really talks about the trying times, so they must always be fine.

Not me. What about you? What’s the cost of this culture of silence?

No single experience captures the trial by fire that is medical education better than the age old practice of “pimping” — the diarrhea-inducing time when an attending physician pelts you with a series of obscure, “read my mind” questions in front of all of your peers and superiors. The questions rain down until you get one wrong. If you’re lucky, it stops there. If you’re not (you usually aren’t), the pelting continues until you become a babbling mess that can’t decide whether to shrink into submission, cry or simply soil yourself. Meanwhile, everyone externally cringes for you and internally wipes the sweat off their forehead because they aren’t under the lonely spotlight.

One day, after my shift, I’m sitting at a coffee table in the hospital, trying to decompress after getting the intellectual noogie of a good pimp. This one came too soon after the death of a young man, husband and father I was caring for. As I obsessive-compulsively bite my nails, my mind jumps between ruminating on the barrage of questions I just got wrong and wondering what more we could have done for that man and his family.  I’m rattled, festering in my own head, and feeling like a failure.

“You all right?” my friend asks as she walks up. She looks just as tired and a little less beaten down than I am.

I want to be strong and perfect like I’m supposed to, so I start reply with, “Yeah, I’m fi–.” Before I can finish, she cocks her head to the side and gives me a look of unbridled disbelief.

“Oh shut up. Come on.” She is unapologetically direct and unrelentingly caring.

I laugh. “It’s that obvious, huh?”

As she flops down into the seat next to me, I unload the last three weeks on her. Moments of grief and frustration, along with the wonderful ones that reinforce the reasons we go into medicine in the first place.

She does the same, recounting the patients who touched her life and the veritable storm that opened up during her Powerpoint presentation on “Diagnosis and Treatment of An Itchy Anus.” Her supervising physician decided to turn a grammatical error into a personal attack on her attention to detail. “What other mistakes will you miss?” he asked. She, too, feels like a failure.

I make a pitiful attempt at a joke about butts, and even though I swing and miss, it at least helps us laugh off some of the absurd aspects of this whole medical student thing. In our self-organized therapy session, we realize we have the same vulnerabilities, fears and insecurities. We’re not alone in this.

I think of the last conversation I had with Pop. This is why I wear his socks. To remind myself to break the silence. To remind myself that we settle our inner turmoil with the support of others. Most importantly, to remind myself perfection is neither a realistic human quality, nor one worth seeking.

“I needed this,” she says. I nod in reply.

Three hundred to four hundred physicians kill themselves every year. One in four of medical students suffer from depressive symptoms, and it just gets worse in residency. Refusing to ask for help, self-doubt, unrealistic expectations of perfection, and loneliness are at the core of these painful stats. We all agree that something has to change. But medicine is a big ship that takes a long time to turn. I’m not sure we can afford to wait for a top down cultural shift to start the conversations around the fundamental highs and lows of the medical student experience. The conversations that remind us we’re not alone.

Every time we choose to swallow the difficult emotions, we waste an opportunity to support ourselves and our colleagues.  If we refuse to connect with and understand our own emotions in emotionally trying times, how can expect to connect with our patients’?

As his health deteriorated, Pop loved to discuss with me his echocardiogram results, medication changes, and fluctuating prognoses. ”My East Coast Doc!” he’d say when I answered the phone. “As your career goes on, you can think of me and all my woes.” He’s referring to the heart failure, the pancreatic cancer and the lung he damaged falling off a ladder.

I told him I would always think of him.  And I do. Every time I put on his socks and go to the hospital, I think about Pop and all of his problems. Just not the ones he hoped.

The Weekly Roundup: A Newsletter Series on Medical Humanities, Leadership, and Personal Development

Since the beginning of 2017, I have been sending a weekly newsletter that features articles, videos, podcasts from around the internet, medical literature, and anywhere else I dig up thought-provoking work.

Below is a sample of what comes in the Round-Up, which will find its way to your inbox on Sunday evenings.

If it interests you, feel free sign up. And if it looks like something a friend or loved one would enjoy, please pass it over to them.

Alright, here’s your sample of the Weekly Round Up:

Design Matters with Debbie Milman: An Interview With Gail Bichler

In this podcast, Debbie talks to New York Times Magazine design director, Gail Bichler, about magazine design and the role of the magazine cover in the digital age.

Despite the surface-level lack of connection to healthcare and the humanities, Gail talks much about being a part of a field during a time of extreme transition, and sticking to a craft despite overwhelming scrutiny and criticism. We all face these challenges in one way or another.

Bichler’s career trajectory, including how she navigated her rise to a fulfilling position, has universal lessons on approaching life’s unplanned turns, leveraging your skillsets, and embracing the one constant in life: change.

Doctors want to give their cancer patients every chance. But are they pushing off hard talks too long? By Bob Tedesch

The cancer therapy market has recently seen a rapid growth in novel drugs that make up the new field of immunotherapy.

While its efficacy has been revolutionary in a number of cases and has provided an especially valuable lifeline for late-stage patients who have run out of options, there is a growing concern that the treatments offer an escape route for physicians who do not want to have the difficult conversation about palliative care and hospice.

As oncologist and palliative care specialist Dr. Eric Roeland said, “It’s almost in lieu of having discussions about advance-care planning, so [physicians are] kicking the can down the street.”

You may hear me talk and write about polarities often, and this is another example of another ongoing tension we have to grapple with in healthcare: Hope and Reality.

The magic lies in uncovering where each patient’s optimum lies and helping them discover how to leverage the upsides of both hope and reality. That may mean hospice, it may mean immunotherapy, and it will likely mean both at different times.

We have to walk with them and be open to course-correction. That may mean making mistakes, it may mean backtracking, and it certainly means being human.

The toxic antidote to goodwill by Seth Godin

What is it? Not caring.

That’s how we lose both the trust of others and a connection to our humanity.

Seth, in his unrivaled ability to pack heaps of meaning in few words, reminds us why the choice to care is perhaps the most important one we make.

A few months ago, I talked about something similar in a short piece I wrote called Heroes Don’t Have to be Talented. Check it out, it’s only a two minute read.

‘A feature, not a bug’: George Church ascribes his visionary ideas to narcolepsy
By Sharon Begley

Abnormal does not mean diseased. In fact, an abnormality in the brain may be the reason why some individuals have a keen capacity for exceptional insights.

World-renowned geneticist and one of the father’s of next generation genome sequencing, George Church, is a prime example and advocate of this idea.

Church has narcolepsy, which he attributes to his most creative thoughts about his research.

From the article: “Church said “almost all” of his visionary ideas and scientific solutions have come while he was either asleep or quasi-asleep, sometimes dreaming, at the beginning or end of a narcoleptic nap.”

We often think that we do patients a service by ‘fixing’ their differences or by decreasing their diversity and bringing them back towards ‘normal.’

Is “sameness” really “better?”

Do we undersell the benefits of diversity when we try to ‘fix’ people that aren’t broken in the first place?

How do our perspectives on medical diversity influence our views on cultural and social diversity?

These are the questions Church’s articles has me asking. What are you thinking?

Medical Students Fall Short on Blood Pressure Check Challenge by Jennifer Abbasi

A recent study on physical exam skills in medical students found that, of one hundred fifty-nine students from medical schools in 37 states who were assessed on an 11-element skillset on BP measurement, only one student demonstrated proficiency on all 11 skills. The mean number of elements performed properly was 4.1.

An article like this precipitates a variety of justifications for the student’s poor performance and a slew of criticisms of medical education.

Some blame the preclinical curriculum and a lack of preparation. Others blame the “hidden curriculum” that medical students see during their clinical years– the series of shortcuts and compromises that physicians must make due to the overwhelming time constraints of the modern medical system.

And still, there’s a third group who says, “who cares? We should be automating this skill by now. Why is medicine so far behind?”

As a proponent of bedside medicine, physical diagnosis, and the seemingly dying art of medicine, you can guess what my take is.

I’d like to hear from you. What are your thoughts? Is this worth worrying about? If so, what can we do to make it better?

Audacious Philanthropy by Susan Wolf Ditkoff and Abe Grindle

From the eradication of polio to the development of the 911 emergency line, to the economic scale of reduced-price school lunches, philanthropy has spurred some of most impactful social advancements. Yes, that kind of philanthropy- the nonprofits that operate to serve their customers, not their shareholders.

Yet, despite philanthropies’ storied past of moonshot successes, today’s list of breakthroughs sees few philanthropic organizations in its ranks. This articles seeks to examine how nonprofits and philanthropy can reclaim its place as a driver of innovation.

I will also add that, as J.D. Kleinke points out in Oxymorons: The Myth of a U.S. Healthcare System, the most cost-efficient, high-value hospitals are the non-profits (see: Kaiser).

Quote of the Week:

“This is an extraordinary time full of vital, transformative movements that could not be foreseen. It’s also a nightmarish time. Full engagement requires the ability to perceive both.”Rebecca Solnit, discussing hope in dark times.

That wraps it up for this week!

As always, feel free forward this to someone who may enjoy it and suggest they sign up by emailing me at jack@jackpenner.com, reaching out on Twitter (@JackPenner), or signing up below.

Best,
Jack Penner

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