Month: July 2016

Categories
Lecture The Medical Commencement Archive

The Power of Not Knowing

Dr. Akram Boutros joined The MetroHealth System as President and Chief Executive Officer in June 2013. He serves as the leader of The MetroHealth System and is its primary public representative, reporting to the MetroHealth Board of Trustees. He works in partnership with the Board to ensure that the organization fulfills its mission and creates strategies that ensure its future success.

Dr. Boutros has more than 20 years of leadership experience in large community hospitals, specialty hospitals and academic medical centers. Most recently, he was President of BusinessFirst Healthcare Solutions, a health care advisory firm focused on clinical  transformation, operational turnarounds and emerging health delivery and reimbursement models. Dr. Boutros previously served as Executive Vice President and Chief Administrative Officer of St. Francis Hospital – The Heart Center in Roslyn, New York, and as  executive Vice President, Chief Medical Officer and Chief Operating Officer of South Nassau Hospital in Oceanside, New York. An internist, Dr. Boutros received his Doctor of Medicine from the State University of New York Health Sciences Center at Brooklyn. He is a graduate of Harvard Business School’s Advanced Management Program and is a recognized thought leader in management systems.

Dr. Boutros also serves on the boards of the Greater Cleveland Partnership, United Way of Greater Cleveland, the Cuyahoga Community College Foundation and the Cleveland Ballet. Most recently, he served as Chair of the American Heart Association 2015 Cleveland Heart Ball, the most successful in the city’s history. He has been named to Power 150 by Crain’s Cleveland Business, Power 100 by Inside Business Magazine and EY 2015 Entrepreneur of the Year for Community Impact in Northeast Ohio.

Twenty-eight years ago, I sat where you sat, thought what you thought, and asked myself, is medical school really over? 

Will I be a good doctor?
What will the future of health care look like?
Where do I fit into that future?
Will I survive those coming changes?

My answer to each of those questions was the same: I don’t know. No one knows. But I do know a few things after nearly 30 years in this crazy profession that you are a “flip of a tassel” away from entering. I learned the first one when I was a little older than most of you.

I was in my second year of residency, near the end of one of my every-third-night ICU rotations. Exhausted, I had fallen into a deep sleep when a nurse woke me to tell me a patient who was septic – filled with infection – had become acidotic – possessing a level of acid in bodily fluids so high, it can kill you. Still foggy, I sat up in bed and said, “Give her an amp of bicarb.” It was a reflexive response. I knew bicarbonate, a base, would correct the acidosis. And as soon as I said it, I laid my head down and fell back asleep.

Five minutes later I woke again, covered in cold sweat. I’m not just using that phrase here. I was in a cold sweat. Somewhere in my subconscious, I remembered that this woman, this septic patient, also had end-stage renal disease. Her kidneys had failed. And she was retaining so much fluid it was straining her heart. As many of you know, bicarb is short for sodium bicarbonate and sodium is salt and that salt would make her retain even more fluid. I had just ordered a remedy that could kill her.

Fully awake, heart racing, I ran to her room. I was too late. The nurse had followed my orders. What I experienced next was panic. My stomach churned. My heart raced even harder. Will she die? God, I hope not. How am I going to fix this? Who should I tell? What should I do? Is this the end of my career? What the hell is wrong with me?

No one likes to risk their reputation, to claim they made a mistake, especially a potentially deadly one. But at 2 a.m., I called my ICU attending. I called the patient’s attending. I called the nursing supervisor. I called the renal fellow. And I told them all the same thing: “I screwed up.”

Nobody yelled. And nobody fired me. Instead, together, we agreed to assemble a team to perform ultrafiltration to draw off the fluid – before it did its damage. It worked. The patient made it. She survived. Not because of me. Because of the team that gathered around me. They all wanted her to live. And they all wanted me to succeed.

Everybody wants you to succeed, too. That’s the first thing I want to leave you with today, one of the things I hope you’ll never forget: We are ALL rooting for you. Your teachers are rooting for you. Your bosses are rooting for you. The institution you work for is rooting for you. So are your patients, your family, your friends, and your spouse. ALL of us. We love you. We need you. We want you to be happy, confident, good at what you do, and in love with it. We want that for all kinds of reasons.

One of those is that someday we may need you to take our pain away, to help us walk again, to give us back enough energy to play with our kids or grandkids, to save our lives. Close your eyes now, for just a minute, and picture in your mind, the world of people who are behind you. So many of them are here today. Imagine them, in the stands, on their feet, cheering you on. And whenever you find yourself in a tough situation, come back to that image. Imagine everyone who cares about you cheering you on. Because we are.

I have another message today. This one comes from a different moment early in my career, another one I’ll never forget. It was July 1, 1988: the first day of my internship, and my first day as a doctor. I was on call and because my last name begins with B, I got the first admission to internal medicine: a transfer from another hospital. When I walked into the room in the ED, a middle-aged woman was sitting up in bed, dressed in a hospital gown, looking very anxious. I began with the textbook question: “What brought you to the hospital?”

“They think I have Churg-Strauss vasculitis,” she said.

I remembered that I’d studied the disease awhile back. I remembered that it was serious. But I couldn’t remember what it was or what organ system it affected. In fact, I couldn’t remember anything else about it. I felt unprepared, like I had nothing to offer, that I was useless.

But I kept going. I thought, alright Akram, just keep asking questions – as many questions as possible – and maybe you’ll get a clue. If that doesn’t work, try the ‘fake it ‘til you make it’ method. Maybe that works for doctors, too. I took a detailed history, asking questions about diseases in her family and what medications she was on. As I was wrapping up, she looked at me and said “So what do you think, Doc?”

I stopped and thought for a few seconds. I thought about saying “Oh, we’ll have to see,” or “We need to run some tests” or something else that would make me sound like I really knew what was going on. But when I looked at her again, I saw how concerned she was. And different words popped out of my mouth.

“I don’t know.”

I was embarrassed to admit it. But, to my surprise, she wasn’t angry or afraid. She chose understanding instead. Immediately, I promised her that I would learn as much as I could about Churg-Strauss before the next day. I told her that every day she was there, in the hospital, I would do my very best to gain the knowledge I needed to take good care of her.

She died. But it was 13 years later. And every one of those 13 years, she was my patient. During those years, she told me, more than once, that the reason she trusted me with her life was because I had been honest with her. That honesty humanized me. Those three little words – “I don’t know” – made her believe in me.

I kept my promise to her. I sought out those who knew more about her deadly vasculitis than I did. And I asked them to teach me what they knew, to be my partners in her care. Together, we gave her 13 years she might never have had.

“I don’t know.” Don’t ever be afraid of those words. They are the start of something beautiful. And they’re a reminder, every day, that we are doctors, not Supermen or Superwomen.

In America, we celebrate the Lone Ranger. And what we really need to celebrate is the Fantastic Four, no The Justice League. Sometimes – no, often – you need the Elongated Man, the Red Tornado and Wonder Woman to get the job done. Having Martian
Manhunter with his genius intellect and regenerative healing helps, too.

Remember: You don’t have to be able to do it all or know everything. Your teachers don’t expect you to. Your colleagues don’t expect you to. And your patients don’t expect you to. The only person who insists that you have all the answers is you.

Say “I don’t know.” It’s one of the smartest, bravest things you can say. It will take the pressure off. People will trust you. Nobody believes a know-it-all. Amazing things will happen when you say “I don’t know.”

I think the late poet Wislawa Szymborska said it best. In her 1997 speech accepting the Nobel Prize for literature, she talked about why she loved that three-word phrase:

“It’s small,” she said, “but it flies on mighty wings. It expands our lives to include the spaces within us as well as those outer expanses in which our tiny Earth hangs suspended. If Isaac Newton had never said to himself “I don’t know,” the apples in his little orchard might have dropped to the ground like hailstones and at best he would have stooped to pick them up and gobble them with gusto. Had my compatriot Marie Sklodowska-Curie never said to herself “I don’t know,” she probably would have wound up teaching chemistry at some private high school for young ladies from good families, and would have ended her days performing this otherwise perfectly  respectable job. But she kept on saying “I don’t know,” and these words led her, not just once but twice, to Stockholm, where restless,
questing spirits are occasionally rewarded with the Nobel Prize.”

Be restless, questing spirits. Explore, always. Exploring leads to discovery, and discovery to whole new worlds. And those worlds to the theory of radioactivity, the laws of motion and great things we never imagined were possible, things that make the world a better place.

That is why you – with this beautiful knowledge you’ve spent years acquiring – are here. You are here to make your patients better, your communities better, and the world better. And you do that by being restless, questing spirits. You do that by saying “I don’t
know.” Those three words are the start of something beautiful. THAT is one thing I know for sure.

 

Akram Boutros, MD
Northeast Ohio Medical University
Commencement Address

The Medical Commencement Archive Volume 3, 2016

 

 

Categories
Clinical Opinion Public Health

The Opiate Epidemic: A tragedy for patients is a warning to physicians

As student doctors, we are entering the medical field in the middle of a raging wildfire: an “opiate abuse epidemic.”[1] The media would have us believe that addicted patients are perpetuating the problem of opiate misuse and overuse, but opiate misuse and overuse might only be a symptom of a larger problem: a medical culture in which physicians fail to practice good prescribing habits.

Overprescription and subsequent overuse of opiates is undoubtedly further complicated by the ambiguous disease process of chronic pain, a topic which deserves its own time and attention. Questioning provider prescribing practices, however, may be the only path forward in making sure that the tragedy of this crisis does not escalate further. In my mind, there are several features that characterize ideal, quality prescribing habits. First, quality prescribing should place an emphasis on patient education about the drug being proposed. A patient should also be screened for the risk of developing any side effects. Included in this should be a review of any other medication that the patient is currently taking, and potential drug-drug interactions. If necessary, a pharmacist should be involved in this evaluation. Finally, a plan between the physician and the patient to manage care should be established. For medications known to be highly addictive, this might involve a phone call a week later, and a follow up in-office appointment to see how the patient is reacting to the prescribed drug. If at any point these benchmarks for safely prescribing a medication cannot be met, then the treatment choice should be reevaluated.

It was curious timing that in the middle of this epidemic, on May 5, Hawaii House Bill 1072 quietly died in the Hawaii state senate.[2] Bill 1072 “Relating to Prescriptive Authority for Certain Psychologists,” was meant to allow psychologists to have medication prescribing privileges in order to compensate for the Hawaiian physician shortage.[3] At first, I was relieved to read that the bill had not passed the Senate. As a future physician, it’s unsettling to imagine another profession encroaching on the special modalities that we have at our disposal to treat patients, such as our prescribing privileges. But then I had a second thought. If the average physician fails to exercise high-quality prescribing practices, then perhaps clinical psychologists, who by definition study human behavior, might actually make better opiate prescribers than the average physician. In general, psychologists spend time listening and learning about their patients’ history and behavior patterns, offer counseling education, and meet with their patients on a regular basis. This model of health care encompasses many of the aspects needed for ideal prescribing habits, as previously described.

You don’t need a medical degree to understand that opiates are powerful drugs that have many side effects and can lead to addiction.  What we don’t yet seem to understand, as a profession, is how to effectively communicate these risks, or evaluate the best patient candidates for the use of opiates. A 1992 study by Wilson et al. found that when physicians increased the time of their patient interactions by just 1.1 minutes, there was a statistically significant increase in the amount of health education that a doctor could incorporate into a standard visit.[4] While it’s difficult to get specific data about the average length of a typical doctor’s visit[5], a 2013 article from the New York Times suggests that the average new physician spends only eight minutes with each patient.[6] If you have ever participated in a standardized patient encounter as part of your medical school curriculum, you have undoubtedly experienced the struggle to perform a history, physical exam, and basic patient counseling in 14 minutes. When you take into account the level of patient screening and education that the prescription of opiates, or any narcotic, demands, it seems implausible that a doctor can satisfy the requirements necessary to safely discharge a patient with an opiate prescription in such a short span of time.

In response to the opiate crisis, the ultimate long-term goal for the medical community should be to better understand chronic pain, and devise alternative treatment modalities for this diagnosis. In the meantime, however, the medical community should view this unfortunate situation as a call to reevaluate the quality of our prescribing practices. Current and future doctors need to commit ourselves to being worthy of the privilege of the prescription pad, so that it remains a treatment tool and not a source of patient harm.

References:

  1. http://www.cnn.com/2016/05/11/health/sanjay-gupta-prescription-addiction-doctors-must-lead/index.html
  2. www.civilbeat.com/2016/05/2016-session-ac-for-schools-help-for-housing-and-homeless/#.VyzIubQqa3o.mailto
  3. http://capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=1072&year=2016
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881485/
  5. http://www.ajmc.com/journals/issue/2014/2014-vol20-n10/the-duration-of-office-visits-in-the-united-states-1993-to-2010
  6. http://well.blogs.nytimes.com/2013/05/30/for-new-doctors-8-minutes-per-patient/

Featured image:
Medication by Gatis Gribusts

Categories
General Lifestyle

Goals for the Summer

The beginning of December is when it begins. Around winter finals, people already start to ask – What will you do over the summer?

“Should I apply to a summer fellowship?”

It’s reasonable that we want to make the most of the summer. Considering the prevalence of ordered, dutiful personalities in medical school[1], it’s no surprise that this precious time – the last summer vacation of our lives (at least, in the US school system) – is wrought with indecision.

“Are you doing research over the summer?”

We go to second-years and faculty to ask for advice. We post on Facebook or other social media outlets. We ask career counselors. They all say to take things easy. Second year is hard, so do something that is important to you. Go travel. Spend time with family. They say things like, you only have to do research if you want to go into a competitive specialty. We search Google and find resources about summer fellowships and research opportunities.[1]

“What should I do over the summer?”

I am reminded of the memoir When Breath Becomes Air, written by the neurosurgeon-in-training Paul Kalanithi. In the book, Kalanithi writes about a similar situation during his undergraduate sophomore summer. He had to choose what to do with his summer, because he had been accepted both “as an intern at the highly scientific Yerkes Primate Research Center, in Atlanta, and as a prep chef at Sierra Camp, a family vacation spot for Stanford alumni on the pristine shores of Fallen Leaf Lake [… which] promised, simply, the best summer of your life. […] In other words, I could either study meaning or I could experience it.”[1] Ultimately, he chose the job as the prep chef. And despite the outrage of his biology mentor over the lost research opportunity, Kalanithi still became a neurosurgeon.  He said his experience at the camp was meaningful, invigorating, and had lasting effects on his perspective when he returned to school. It’s a little different in medical school, but the principle is the same.

“When you look back on the summer, how will you feel?”

I struggled to decide what to do with my summer. I felt like there were a lot of options, but was unsure of what to pursue – I could conduct research on campus, be a medical volunteer at free clinics, work at a global health mission, spend time with family, travel with friends … there were too many options. I felt like all of the options were possible as long as I submitted an application on time. The most difficult part was that at my school, summer lasts only one and a half months.  Ultimately, the time constraints limited me to only one or two activities, and I wanted to choose an activity that would be “the best summer of my life.”

I had started the application for a summer research fellowship, submitted it, and was waiting to hear back. Meanwhile, I heard friends talking about how they were planning to go on trips in-state and

abroad, get married, or just spend time at home. Other friends were awarded fellowships at other academic institutions. I wondered how valuable it would be for me to spend another summer putting in forty or more hours of research a week when I had spent a number of undergraduate summers doing that before. In fact, I realized, my last real break was the summer between high school and undergrad.

In my final year of undergraduate studies, a retiring professor told the class that he was most excited about the opportunity for extended break from academia. He expressed regret that he had not taken more breaks throughout his career. My friend and I had discussed this together; we wondered whether a break from school or work could really be as meaningful as he said. I’m beginning to realize what he meant now, as my classmates and I fight through burnout during our first year in medical school. The importance of self-care cannot be overlooked.

I weighed the pros and cons of each option. When it came down to it, my ideal break consisted of: (1) reconnecting with family and friends, (2) spending time with literature – both reading and writing, and (3) exploring future career options. While important, career-building was not the most important summer activity because I still have the rest of my training and the rest of my life to work on it. For me, time with familiar people and literature are sources of enduring happiness. At the end of the day, I take comfort in cultivating these life experiences. I worked hard to create an opportunity that would incorporate all three of these items. I’m planning to spend the summer at home, relaxing and working on a small project I managed to set up with a mentor nearby.

For those coming up with their own summer goals, I suggest considering the following points:

  1. What are the pros and cons of the options you have considered so far?
  2. How much time can you allot to each of your options?
  3. Is there something you would regret missing out on?
  4. What will rejuvenate you for the upcoming year?
  5. If you could do anything, how would you spend an ideal summer?

References:

  1. There was an actual study published on this. Lievens, et. al. (2002). Medical Education, 36, 1050–1056.
  2. Interested readers may want to peruse the following pages:  “Summer Opportunities for 1st-Year Students” from Indiana University and “Summer Opportunities for Medical Students” from the Medical University of South Carolina.
  3. Kalanithi, Paul. (2016). When Breath Becomes Air. Random House, New York, NY. 31-32.

Featured image:
San Francisco Peaks from Kendrick Mountain Fire Lookout Tower by Al_HikesAZ

Categories
Clinical Reflection

The Importance of Geriatric Medicine

When the infamous question “what kind of doctor do you want to be?” has been thrown my way, I have typically responded by throwing out three fields of medicine that I currently find interesting: pediatrics, endocrinology, and geriatrics. However, while the usual response includes much satisfaction about 2 of my potential career choices—with lots of oohs and ahhs about the joys of treating children, and the approving nod for endocrinology because, hey, diabetes—the standard, usually skeptical, follow up question I receive is: why would you want to take care of old people if they are just going to die soon anyway? Isn’t that…depressing?

Despite these ageist misconceptions, the importance of the growing need for trained geriatricians in the U.S. cannot be denied. According to the Association of American Medical Colleges, the latest studies are suggesting that by 2025 the number of American baby boomers over the age of 65 will double, and become the fastest-growing age group in the country. This demographic will soon account for 20% of the nation’s population! We can see the practical results of this trend today, as Americans are clearly living longer, requiring assistance in managing chronic health conditions like hypertension, heart disease, diabetes, dementia, etc.

The most alarming fact? The American Geriatrics Society has estimated that 25,000 certified geriatricians are needed in order to provide quality care to this growing population, but currently there are fewer than 7,500 geriatricians in the U.S. In fact, only 44% of the nation’s 353 geriatric fellowship positions are even filled. Geriatrics is considered to be one of the most underrepresented specialties, even though geriatricians have been found to have high career satisfaction.

So, why the disinterest from budding physicians? Financially, geriatrics is often not considered attractive, particularly with nascent residents facing a looming amount of debt right after medical school. Most elderly patients have either Medicare or Medicaid, which have traditionally lower rates of reimbursement for physicians than that of private health insurance. Indeed, geriatricians, despite the extra years of training, have traditionally received less compensation than other subspecialists.

What can be done to help entice young physicians to this challenging field of medicine? While a restructuring of the current reimbursement difficulties would be an ideal fix to this situation, and would help entice young physicians to geriatrics, perhaps more immediately realizable goals should be considered in the meantime. For example, emphasizing the importance of geriatric medicine within medical school curricula is one alternative and realistic way in which to effect change. Students could learn of the intricacies and complexities involved in providing care to this population. This would be particularly relevant for students, as they are the generation of doctors which will be faced with treating a larger population of older individuals, given the statistics mentioned above.

Here is an even simpler idea: help people realize their passion for the field. Dr. Mitchell Heflin, MD, an associate professor of medicine at Duke University School of Medicine, said it best, “People in geriatrics are called to it.” A commonly cited influence for this career choice is meaningful interactions, particularly in childhood, with older populations. I personally can see why I am drawn to this field of medicine, as much of my happiness as a child (and up to the present day), has revolved around my experiences with the elderly. I remember every Sunday I would cross the street and have a spaghetti dinner with our elderly neighbor, affectionately known as Auntie Eva. She was a chain smoking, fiercely opinionated and loving German lady from Buffalo, who could make a killer homemade marinara sauce and meatballs. Even more influential, however, is the relationship I have with my now 83 year old maternal grandmother who has lived with my family since my birth. She not only always babysat me, but also taught me how to fish, ride a bike, tie my shoes, and crochet. Watching her gracefully age with a high quality of life through her 60s and 70s, and then seeing her current struggle with the beginning stages of dementia, has really made me reflect upon the importance of geriatric care in our society and my potential role in it.

So, while I’m not yet sure if geriatrics is in the cards for me, it is obviously a complex field of medicine, critical for the health of the older population and for the health and dignity of our society at large.

 

References:

https://www.aamc.org/newsroom/reporter/april2015/429722/fewer-geriatricians.html

http://health.usnews.com/health-news/patient-advice/articles/2015/04/21/doctor-shortage-who-will-take-care-of-the-elderly

Featured image supplied by the author

Categories
Clinical Emotion Reflection The Medical Commencement Archive

Compassion, The Heart of Medicine

Dr. Rob Horowitz is an Associate Professor of Clinical Medicine and Pediatrics, and is board-certified in Internal Medicine, Pediatrics and Hospice & Palliative Care Medicine. After 14 years of working as a rural Emergency Physician, in 2012 he moved his professional come to the University of Rochester Medical Center division of Palliative Care, where he cares for children and adults who have serious illness. Dr. Horowitz also established and served as Medical Director of URMC’s Adult Cystic Fibrosis Program from 1999 until 2015.

In addition to his clinical duties, Dr. Horowitz is Director of the Medical School’s Year 2 and Year 3 Comprehensive Assessments, which are longitudinal formative assessments of student communication skills, medical knowledge and professionalism utilizing patient-actor interviews, multi-source feedback, peer- and self-assessments, and other modalities. He also teaches medical students in multiple other small and large group settings and facilitates several groups for clinicians, including Balint groups for physicians and Nurse Practitioners, and a support group for Palliative Care Unit nurses, techs and others.

Hello Class of 2016 and hello to your family, friends, colleagues and dignitaries. What an honor, that you invited me to deliver your Last lesson from the University of Rochester School of Medicine and Dentistry faculty. It will be a brief one, less than ten minutes; and it will be a review, a reminder of what you already know. Or, and I say this with sadness and some urgency, it may be a reminder of what you once knew, and may be in the process of forgetting. This Last Lesson is grounded in words from Francis of Assisi, which I paraphrase here:

Work of our hands is labor.
Work of our hands and our head is a craft.
Work of our hands, our head, and our heart is an art.

THIS is the last lesson: doctoring is an art, a work of your hands, head and heart, or more prosaically, a work of skills, knowledge and humanity. This reminder is important, even for you, who were socialized here in Rochester, the home of biopsychosocial medicine. In fact, it’s a response to recent conversations I’ve enjoyed with many of you, who, poised for internship, wondered whether health-care-the-business has taken the heart out of medicine- the-calling. The answer is a resounding NO. But let me respond directly to your words, first about hands and head. Here are two quotes from you, representative of many others:

I just don’t know enough to be a good doctor.
I’m about to be revealed as a phony.

I respond with a story from long ago and yet not so long ago: twenty three years ago I was a Med-Peds intern here in Rochester, just completing my first Medicine rotation at Strong Memorial Hospital, when in Morning Report the chief resident asked me to offer a differential for the case. I was paralyzed. I had no idea how to explain the patient’s symptoms. I tried to smile and charm my way through it, but I stumbled and fumbled, until a fellow intern completed the task that I couldn’t. I felt ashamed…revealed as a phony, an imposter.

As you know, aversive conditioning is deep, and this experience stuck with me. In the succeeding years, whenever I saw a particular colleague who witnessed my humiliation on that day long ago approaching down the hall, I was tempted to, and sometimes DID, turn in the opposite direction, so I wouldn’t have to feel his scorn.

Sounds silly from this vantage, nearly a quarter century later, doesn’t it? In fact, a medical student suggested so last year in response to me sharing this story. He challenged me to find out if my impression was accurate. And so I did. Last June, seated behind me in Grand Rounds was that well-admired physician. I took a deep breath, turned around, and asked him what he recalled about that infamous incident, my unmasking. His response was, “Are you kidding, Rob? I was too busy feeling like a fraud myself to take
in anyone else’s difficulties! Sounds like we were in the same boat.”

What a gift of relief his words were! A few minutes into Grand Rounds, he put a ribbon on the gift when he tapped me on the shoulder and whispered, “Y’know, Rob, I’ve always thought you were a pretty smart guy.”

There are two morals here: First, you can’t pack all the information you will ever need into your head. In 1950 the doubling time of medical knowledge was 50 years; in 1980, 7 years; in 2010, 3.5 years. This means during your tenure here—whether 4 years or 13 years—the base of medical knowledge has more than doubled and, for some of you, several times over! So, of course, please learn from your knowledge gaps, and master how and where to seek answers. And please recognize that knowing it all is not the most important  measure of our competence as doctors.

Second, the collision between our cognitive limits and our inherent drive and perfectionism, which made this professional  achievement possible in the first place, is a perfect recipe for self-doubt and self-judgment. And if these become our lifestyle, we will live a  disheartening and depleted life. Please be kind to yourself, and find in your community colleagues and mentors who are open to genuine reflection. Don’t wait 25 long years, like I did, or forever, to make peace with your humanity.

Now, what about the Heart component of Doctoring? I will share two quotes from you, similar to many others:

I know empathy is important, but there isn’t enough time to be empathic.
I’m working so hard to be smart and productive, I’m afraid I’m losing my caring.

Let me respond with a second story, a fresh one about the profound opportunity for compassion in simple moments. Last Friday morning, into the exam room stormed my new patient, a 50-something year old woman I’ll call Wendy, who has widely metastatic cancer and severe pain, for which she was referred to me. You see, I’m a palliative care physician, and as such, I am a pain specialist. She sat opposite me and as she launched into her agenda, she leaned forward so far that I was forced to lean back.

She damned the medical system, and she cursed the siloed subspecialists, and she asked why the hell she should trust me, yet another siloed subspecialist, to help her, or to even care. I asked if I might share an observation with her. She nodded. I told her, “I want
to help make sense of what’s going on, and to care for you and help you, but your manner appears so angry, so critical, I am not sure how to reach through it to you. Can you help me?” She softened a bit, and responded, “I’m afraid that if I stop being angry, I’m going to cry.” I inched closer, until our knees were almost touching, and looking into her now moist eyes, I said, “Then cry.” She gasped and her head bowed, tipping forward as if she was collapsing, and to stop her descent, I reflexively leaned forward, until the tops of our heads were gently touching. We were posed like an A-frame, and she wept. I put my hand on her shoulder and told her, “I am with you, Wendy.” And between sobs, she stuttered, “Yes…now… I know.”

There are two morals here. First, you can choose to cultivate the habit of compassion. Indeed, I share this story not to show off my compassion-finesse, but to demystify, to define and to normalize it. We respond compassionately to suffering simply by witnessing it, approaching it, and inquiring about it. And by that alone, we offer healing. And it doesn’t have to take a lot of time.

Second, it is vital to be compassionate to both your patients AND to yourselves. Because just as you can’t possibly know everything that matters, neither can you possibly tend to all those in need. Please remember that you actually DO need to sleep and to eat,
to tend to your spouse, your partner, your children, your friends, your inner life, and your pleasures.

So, this last lesson is a reminder of what you knew when you first came here to enter this amazing, privileged profession: Hands, head and heart are all three essential to the art of doctoring. If you choose to make compassion your default mode, then you will know definitively—in your own heart—that health-care-the-business CAN’T take the heart out of medicine-the-calling.

You can only imagine how inspiring it is, from this stage, to look upon you, our colleagues. To celebrate you, to be awed by you, and to know with great confidence that your skillful hands, your brilliant heads, and yes—your loving, beautiful hearts will be a blessing to your countless beneficiaries, your patients, who now await your arrival. For this we are forever proud and grateful. Congratulations.

 

The Medical Commencement Archive, Volume 3, 2016

Dr. Rob Horowitz, MD
University of Rochester School of Medcine
Commencement Address

Categories
Clinical Reflection

Could I be wrong?

Physician overconfidence is thought to be one contributing factor to diagnostic error, and occurs when the relationship between accuracy and confidence is mis-calibrated.1 The relationship between diagnostic accuracy and confidence is still indefinite, but it is hypothesized that if confidence and accuracy are aligned, then appropriate levels of confidence could cue physicians to deliberate further or seek additional diagnostic help.2

A recent study by Meyer and colleagues, aimed at evaluating the relationship between physicians’ diagnostic accuracy and their confidence, found that physician confidence was related to how often they requested a critical additional resource. Additionally, the study found that diagnostic accuracy decreased when physicians were faced with more difficult cases, while confidence decreased only slightly with difficult cases. They noted that diagnostic tests were requested less often when confidence level was higher, regardless of whether or not that confidence was correctly employed. “In essence, physicians did not request more second opinions, curbside consultations, or referrals in situations of decreased confidence, decreased accuracy, or when diagnosing difficult cases.”3 The findings from this study suggest that physicians might not request the required additional resources when they most need it.

Students are often so sensitive to criticism that they are reluctant to give any to their colleagues. This is one area where the culture of medicine can be improved. By using feedback from others and self-reflection, we may be able to improve our diagnostic reasoning.

We are taught to think that everything needs to be rechecked and reconsidered when it comes from an outside source. But what if we turned that clinical skepticism inward? When you are right, you are going to save lives and figure out the patient’s problem. When this happens, it’s always going to be a wonderful thing. But how many more times can we get it right if we make it a habit to ask ourselves, “how could I be wrong here?”

Jason Benham said, “Your greatest weakness is often the overextension of your greatest strength.” Essentially, when a strength is over-extended, you get breakdown. But when a strength is turned into a stretch, and you’re flexible enough to bend, you will not break. Take time to occasionally step back from a difficult case, consult a textbook or run a different test, and make sure you are solving the correct problem. Mistakes will happen. When errors occur, acknowledge them, discuss them with colleagues and the patient, make efforts to correct it, and move on. In medicine, where the consequences of shortcomings and misjudgments can be dire, we can all benefit from encouraging more of these types of discussions.

References:

  1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5)(suppl):S2-S23.
  2. Graber ML, Berner ES, Suppl eds. Diagnostic Error: Is Overconfidence the Problem? http://www.amjmed.com/issues?issue_key=S0002-9343%2808%29X0007-5.
  3. Meyer, Ashley N. D., Velma L. Payne, Derek W. Meeks, Radha Rao, and Hardeep Singh. “Physicians’ Diagnostic Accuracy, Confidence, and Resource Requests.” JAMA Internal Medicine JAMA Intern Med 173.21 (2013): 1952.
  4. Schiff GD. Minimizing diagnostic error: the importance of follow-up and feedback. Am J Med. 2008;121(5)(suppl):S38-S42.

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