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

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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.

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