On Being A 'Real Doctor'

Have we created a system that is more 'careless health' rather than 'health care'?

A medical colleague of mine recently shared the below video with me that strangely struck a chord. Trust me...it's worth 4 minutes out of your life to view.

Sadly, in my opinion, there is some truth to the narrative.

Have 'real doctor's' become so out of touch with reality? Are we nothing more than mere paper pushers? Is direct patient care nothing but a faded memory?

I would argue that without a unified and experienced voice -- OUR voice -- we risk such an outcome.  The real doctors become 'Watson' like figures while everyone else shuffles electronic paperwork to keep the system afloat. While I realize this is a polarized stance, my purpose in sharing this entry is to stir and excite this health community to take action.  As I am sure it comes as no surprise to anyone on this thread, our ailing health system is plagued with inefficiencies - which only means it is equally ripe with opportunity. But who is going to answer this call-to-action? Are we to assume that our non-health professional counterparts are looking out for our best interest?  My experience tells me - not likley!

Having sat on both sides of the table, we as diversified health professionals, need to be an integral part of the conversation.  Although I am relatively new as a contributor to the group (but longtime follower) I tip my hat to the authors, members, and voices on the FreelanceMD network.  Many of you, including myself, have taken the leap out of direct clinical care to try and help fix this mess.  This is clearly a group of doers, not just talkers.  I observe that together we make up a diverse set of skills and health backgrounds that can clearly make an impact. Lets take advantage of that.

At its most vulnerable time in medical history, I argue that our health system NEEDS people like us. We are not a luxury, but a necessary voice to help spur & drive innovation in health care so that, one day, we can all be proud once again to say we are 'real doctors'.

Want to continue the conversation? Join me in my pursuits for leading health innovation!

Cheers,
Gautam

Physician Leadership in Driving Culture Change

Getting your organization aligned with your vision and plan

Whether you are a physician leader in industry or clinical practice, you know you need to get your organization to a new place.  The way everyone in your organization works, thinks, and behaves may (or may not) be okay—but to achieve your aspirations for the future, you are going to need a better approach.  Your challenge is to move your organization from where it is today—to where it needs to be in the future.   And you need to do it before the future runs over you like an avalanche. 

No matter where you wish to take your organization, you will need the support and commitment of your colleagues—if you are to succeed.  However, getting your people unstuck—getting them not only to embrace your vision, but to change the way they work and think to achieve it—is often more challenging than defining the goal or objective. 

The key to achieving meaningful change in your organization is to align every thought, action, and behavior (the expression of an organization’s culture) with a clearly defined and well-communicated vision.  While this can seem to be a daunting task, you can achieve alignment if you break the process down into manageable steps.      

Know where you want to go

The first thing you need to do is be clear.  Create your leadership team and mutually define where your organization is going and why.  Work with this team to clearly and unambiguously justify the decision for change.

Avoid the “anywhere but here” cop-out

Clearly identifying and communicating the need for change is not the same as knowing where you want your organization to be in the future.  Some leaders initially convey their objectives in terms of what is not working in their organizations today.  The focus should instead be on where you are trying to take your organization.

Once you start the “makeover,” people need to know where they are going if they are to focus their energy and sustain the momentum.  Otherwise, they will continue to drift or, even worse, return to the old ways you are trying to escape.

Your team: don’t leave home without it

There is probably no group in your organization more emotionally invested in the old ways than your leadership team.  The process of getting this team fully committed to a shared vision can be messy and slow.   If the team is not on board regarding the vision, the rest of the organization will be left in the dark regarding the direction and benefits of future change efforts.

If your leadership team is not aligned with your vision, you either have the wrong vision, the wrong team, or you have not effectively communicated your perspective.  In the early stages, some will line up along one side or the other.  Focus on those in the center; this is where the leverage for change lies.  If you can move the majority of these team members to your point of view, the few on the other side will either move to the middle or move on.

Use the vision as a filter for decision-making

Ideally, your vision—along with other descriptors, such as the mission (or purpose) and values of the organization—would serve as a template or “filter” for making decisions.  Some refer to this as the “social architecture” of the organization.  What’s important, however, is not what you call it—but how you use it. 

The description of your organization’s future goals and plans is critical; it is the highest level template for the many decisions made in your organization every day.  The most effective models are clear and concise statements that can be fleshed out with open dialogue to ensure that everyone shares the same understanding of their meaning.

Create, communicate, and translate

The process of establishing a clear vision and direction for your organization is as much about internal communication as it is about planning. The challenge is not in formulating a vision; it is in making it meaningful to everyone in your organization every time they must make a choice.

Communicating your vision is as important as the vision itself—and believe it or not, you cannot over-communicate your vision.  A well-communicated but poorly translated vision is just noise.  On the other hand, a well-communicated and well-translated vision has a good chance of influencing behavior.  Many of the vision statements on plaques on waiting room walls probably don’t lend themselves to easy communication and translation.  Because your vision is the heart of your change communication strategy, it must be crisp and concise.  There can be a lot of supporting language, but the statements themselves—and what they stand for—should be accessible to everyone in the organization for every decision that needs to be made.  

If you aren’t going to measure, then don’t bother

You’ve heard it before: “what gets measured gets done.”  It’s still true.  An effective measurement system that scans both the lagging and leading indicators should become the framework for managing change.  It can also allow for course corrections.   Since you can’t make every decision yourself, your measurement system will become one of you most critical tools for communicating what is important—and should be considered in every decision. 

The best measurement systems are those that are simple and have the most impact.  After clarifying the desired destination, the leadership team creates a “dashboard” of the few, critical performance indicators.  This provides a framework for monitoring the progress of change and making course corrections as necessary.

Some management teams tend to focus on a litany of financial measures.  While financials are important, they are also retrospective—like looking in your rear-view mirror.  They can only tell you where you have been, not necessarily where you are going.  It’s also important to ensure that these measures are cascaded and aligned throughout the organization.  So, if what gets measured gets done, then what’s getting done must be aligned with what you are trying to achieve. 

Stop talking about change

Getting everyone to align their behavior with your vision for the future usually means they will need to change, at least in part, the way they work and think.  And most people seem to resist change.  But then, what they  really resist is the loss of control over their work lives—and the resulting uncertainty about the future.

If this is the case, then it is not a stretch to figure out how you, as a leader, can help your people begin to retool and regain control.  Of course, the starting point is an effective two-way dialogue.  Present the case for change in such a way that helps everyone envision the future while developing a picture of their role in it.   

As physician leaders, we need to stop talking about managing change—and focus on helping our organizations reestablish control over their lives.  If we could do this, the challenge of aligning our organizations becomes much less formidable.

Dumbing it Down is Downright Disrespectful

It's not uncommon that someone will make a comment to me about how we (physicians) need to "dumb it down" when it comes to publishing information for consumers. 

In fact, this is exactly the wrong approach when you are trying to reach people with important health information.  Instead, what we need to strive for is a smart translation of medical science. 

While it's true that people who are not in healthcare likely won't understand a highly technical medical research study (just as doctors probably wouldn't understand a complicated document in another industry), what isn't true is that our patients, readers and consumers need to have information "dumbed down."

A smart translation means that you are approaching your reader with respect for his or her intelligence and knowledge.  Dumbing anything down is just plain disrespectful.  Attitude comes across the written page and seeps into the "take home messge."  A respectful attitude means that readers are more likely to consider the information presented.  Perhaps to heed the advice and even to share it with others. 

Bottom line: everything that physicians write and publish should be done with the goal of offering a terrific translation for a given audience.  I think about this a lot.  When I don't get it right, it isn't because I dumbed my communication down.  I just didn't quite nail the translation.  Great translations aren't easy, but they are incredibly effective.  Offering important health information along with respect is what we should all aim for all of the time. 

I Know What Kind Of Experiences I Will Want My Patients To Have.

By Isaac van Sligtenhorst

I know what kind of experiences I will want my patients to encounter.

We wait.....and wait......and wait in the Clinical Trial department.  Finally, someone whom we presume is the research coordinator, as she fails to introduce herself, enters the room.  My brother did not get into the PI3K inhibitor clinical trial as the company had temporarily halted enrollment.  She starts going into a potential alternative clinical trial for my brother.  She starts spouting off words like 'Bendamustine' and 'Avastin' and then asks if he has questions.  Really?  Short of someone with training in oncology, what person is going to know what these words mean, much less if these are good drug options for him?  I ask for some basic enrollment questions and she's not even up to speed on the specifics.  Great.  She leaves (thankfully) and we wait for the doc....and wait.....and wait.  Nearly three hours after our appointment time, the doc walks in, sits down, and the first thing out of her mouth is, "do you have any questions for me?"  I can hear my brother's frustration as he tries to wrap his brain around what in the world is going on.  We showed up early that morning so he could get bled to determine if he'd be eligible for a PI3K clinical trial.  Now we have a Plan B thrown out there with absolutely no background given and the doc is asking for any questions.  Fine.  I've got one.  "I thought avastin was contraindicated in squamous cell tumors.  Can you please comment on the risk of hemoptysis in combining avastin with a cytotoxic agent in the context of a squamous cell morphology?"  No?  Then please go do your homework first before entering into the room.  I understand this doc was covering for another but have the professional courtesy to at least glance at the chart before entering the room.  Walking in with no prior knowledge of the patient's diagnosis and status just isn't helpful at all.  At least review the bloodwork, but no, we didn't even get that.

Experience #2

Again, we wait.....and wait.....and wait.  This time it’s for Supportive Care to review my brother’s pain management.  The wait is not quite as bothersome because A) we didn't have an appointment and it was only through their kindness that they agreed to squeeze my brother in and B) there's a comfy bed for my brother to snooze in.  But still we wait.  The nurse comes in and he gathers the basics.  Back to waiting and the nurse quickly peaks his head in.  My mom asks, "any idea how much longer it's going to be?"  Just a few more minutes.  The doctor is reviewing my brother's chart.  What a novel concept.

He comes in and begins the usual, "tell me what's going on."  My brother has to be sick of repeating his story hundreds of times over and I suppress the urge to give a quick medical review of him to save time but I know the doctor needs to hear it from the patient's mouth.  From his accent, I can tell the doctor is Canadian, eh, but I don't hold it against him, eh.  He is soft spoken, calm, patient, and attentive.  My brother asks him some questions.  I ask some.  And my mother asks some.  He thoughtfully engages each one in turn, draws diagrams to help explain his logic, and gives firm answers when necessary.  He is clearly in charge of the situation and carries a certain degree of quiet confidence (reviewing the chart helps, too).  But most importantly, he has the presence of mind to look at my brother's pain management thus far, looks at the severity of pain being experienced and says, "this obviously isn't working.  Are you game to try something different?"

I know what kind of experiences I will want my patients to encounter.

About: Having spent nearly 15 years at the bench in drug discovery, Isaac van Sligtenhorst now helps his dad and brother walk through their fights against cancer, while during his spare time he is currently attending med school at UT Health Science Center in Houston, Texas. He blogs at
http://heartofalonelyhunter.blogspot.com

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Leadership Lessons Learned From Childrearing

Effective parenting, like effective leadership, is a demanding, often emotionally draining task.

I have attended leadership courses and conferences, read many books on leadership and many biographies of people I admire as great leaders: George Washington, John Adams, Alexander Hamilton, Thomas Jefferson, Abraham Lincoln, Teddy Roosevelt, Winston Churchill and Martin Luther King. I have been privileged to hold leadership positions in my practice and in my community. While I have learned from all of these sources, I credit my children with teaching me the most about what it takes to lead..

My wife and I, both physicians,  have been blessed with four wonderful children. (The woman just couldn't keep her hands off of me).  It seemed to us that if we could complete medical school and survive our training, raising children would be fairly easy. Gather the data, analyze it and act upon it. It took us a while to realize that being successful parents required a lot more EQ (emotional intelligence) than IQ. The same rule applies to leadership, EQ trumps IQ. Always.

A short parenting vignette and what it teaches about leadership

When our youngest returned from his first semester of college to inform us that he was joining a fraternity with a reputation that would put "Animal House" to shame, we were less than pleased. Our natural reaction was to immediately point out that 1) we weren't paying tuition so he could party, 2) that living in a environment filled with distractions wasn't the best idea for a kid with ADHD and 3) he was already struggling to pass his courses.  Fortunately for him (and for us) his three older siblings had taught us to explore the reasons for his decision. We bit our tongues as he told us how his future brothers would make sure he was studying, how he would focus more on his classes if he could enjoy his time away more and how this move was going to save us money. Instead of reacting emotionally (NFW!), we told him we would think about it and let him know our decision the next day.

The two of us both agreed that while the decision wasn't the stupidest one he had ever made, it certainly wasn't a good one. We openly expressed our anxieties that for all the obvious reasons, the decision could be disastrous, but agreed that telling him he couldn't join would not only make him want it more, but more, importantly, not allow him to learn to experience the consequences of a wrong decision. We were able to identify the long range goal: fostering a morally centered, independent, successful adult who contributes positively to his community, from our short term anxiety: watching our child flunk out of college. We worked out a proposal that focused on the long range goal while limiting (but not erasing) the short term consequences. We would let him join, but only for the rest of this year (two more trimesters). If his GPA didn't improve, back to the dorm it would be. Our job, however, was not to mandate the parameters, but help him set them himself.

"So here's the deal", we informed him the next day, "We know that you are trying your best to stay in school and that this is a struggle for you. We admire your persistence. It sounds to us like you see joining the fraternity as an opportunity to do better in school. Could you tell us how you will be able to tell whether this decision is consistent with you goal?"

He thought about this for a while and surprised us with his proposal. If his GPA didn't go up at least a half a point in ONE trimester, he would move back to the dorm. 

A few weeks later while we were worrying how far his GPA would fall and whether he would stick to his agreement, we received a call from him telling us that he had made a mistake. He should have listened to our concerns about the fraternity. He wanted our OK to move out of the fraternity BEFORE the end of the trimester while he still had a chance of improving his GPA.

So what lessons did we learn from our previous parenting experience that helped us influence (read: lead)  our son to make the right decision. 

 1. Parenting (leadership) is all about influencing others to make the right decisions, not about making the decision for others. When others make their own decisions, they own the decision. They are committed to its outcome and, most importantly, committed to its consequence.

2. Parenting (leadership) is about optimism. It's easy to get caught up with all the things that could go wrong when we enable others to decide. After all, who knows better than us how to do things right? But the more we can infuse others with the optimism that they can problem solve, the less likely they will fail and the more likely they will continue to succeed.

3. Parenting (leadership) is about trust. It's a leap of faith to allow others to make critical decisions, to relinquish control. It's hard work to establish and maintain trusting realtionships with others. But the work is worth the long term gains that trust accomplishes.

4. Parenting (leadership) is about controlling our amygdale (emotions) and empowering our cerebral cortex (reason). We process information that stimulates our amygdale. Others share information that is threatening or evokes fear (too often in a threatening or intimidating manner). Our mammalian amygdale based instinct is toward fight (respond in a hostile manner) or flee (ignore) the information. Effective parent (leaders) separate the message from its emotional context. In the above example, fro instance, through a time out. Decisions made while emotions are prevailing are seldom good ones.

5. Parenting (leadership) is about long term vision. It's about keeping the focus on the ultimate goal rather than controlling the process. Sometimes allowing others to fail is more important than in solving their problems for them.

6. Parenting (leadership) is about accountability. It's about holding ourselves and others accountable for our actions and thier results. If we adopt your plan, what will be the metrics of success, how and when and who will we measure them?  

Effective parenting, like effective leadership, is a demanding, often emotionally draining task. I would argue that nothing, however, is more rewarding.

Physician Income And The Curious Case Of Dr. Benjamin Brown

Physician income analyzed.

I stumbled upon a very interesting blog post the other day.  It's entitled, The Deceptive Income of Physicians, and was written by Dr. Benjamin Brown, a plastic surgery resident who is also the author of the upcoming book, Informed Consent: The US Medical Education System Explained.  Here's how it begins:

Physicians spend about 40,000 hours training and over $300,000 on their education, yet the amount of money they earn per hour is only a few dollars more than a high school teacher.  Physicians spend over a decade of potential earning, saving and investing time training and taking on more debt, debt that isn’t tax deductible.  When they finish training and finally have an income – they are taxed heavily and must repay their debt with what remains.   The cost of tuition, the length of training and the U.S. tax code places physicians into a deceptive financial situation.

The post is an interesting read and has generated a lot of discussion.  As of today, there have been 203 comments.

What I find most "curious" about this post-- aside from the passionate comments-- is the fact that I have never seen physician incomes analyzed like this before.  It is an unfortunate fact that most medical students remain completely naive to the financial implications of their choice of profession, and their potential specialty choices.

I wrote a recent blog post about this very issue where I quoted Dr. Robert Doroghazi, author of the book, The Physician's Guide to Investing: A Practical Guide to Building Wealth , as saying: 

"I believe the position of the academic medical establishment to deny medical students financial instruction is naive, hypocritical, and indefensible.  They should acknowledge that money is important.  It is never as important as your patient.  It is never as important as your family, your health, your freedom, or your integrity.  But is is important."

I couldn't agree more.

The medical establishment in this country should be ashamed of themselves.  Instead of having very frank and necessary discussions with medical students about the financial implications of becoming a physician, our medical leaders turn a blind eye to this very real need, and medical students are cast out into a harsh economic world with little financial knowledge to protect themselves and their families from potential financial ruin.

It is really an embarrassment to the medical community that this information isn't coming from the academic medical establishment, but a surgery resident who did the work in his spare time.

Thanks to Dr. Brown for making this information available to all of us.  I look forward to reading his upcoming  book.

Crossing International Borders As A Physician

If you’ve never had the pleasure of crossing a border into a remote part of a developing country, you’re in for a real treat.  Some of the best travel stories-- both good and bad-- occur at border crossings.

While most crossings involve little more than a little eye contact and a perfunctory paperwork inspection, things can turn bad in a hurry for those who are unprepared.  Stories abound on the international travel circuit of travelers being detained—or worse—when attempting to cross a border in a less-than-appropriate fashion.  If you’re going to be traveling in remote, undeveloped regions, it’s best to have a plan for handling the crossing of national borders.

For many Westeners—especially the inexperienced physician traveler—the idea that someone in a country that they’re “trying to help” might not believe their good intentions seems preposterous.  Regardless of your intentions, however, you can run into problems.

You might be the nicest, most altruistic person in the world but look at it from the perspective of a border guard:  you’re foreign, you probably don’t speak the native language, you might appear rude due to your dress or mannerisms, and if you’re a medical officer you’re probably carrying lots of suspicious-looking pills, tablets, instruments, and other doo-dads. 

In the first chapter of our Expedition & Wilderness Medicine textbook, Dr. Howard Donner has some helpful tips for dealing with border crossings.  I’m quoting Howard here at length: 

Don’t carry white powder in zip lock bags.  As obvious as this may sound, it is amazing how tablets of all sorts tend to break down with humidity and then slowly disintegrate in zip lock bags. A poorly identified zip lock bag, with pulverized white medicine inside, presents a rather suspect impression to a customs official.  Try to be meticulous with your drugs.  Place your medicines in clearly labeled zip lock bags or medicine vials. If you choose to use zip locks, protect them from physical damage inside of a sturdy kit or case.   The more organized the kit looks, the less dubious the custom’s officials seem to look. 

Carry a copy of your medical license.  Showing a customs official a photocopy of your medical license carries a bit more credibility than stating, “but I’m a doctor, really." 

Present a letter of introduction.  Customs officials seem to love embossed stationery or letters embellished with gold seals. These blank forms can be easily purchased through most office supply stores.  Even if you’re not traveling with the National Geographic Society, you can print up your own letter on embossed stationary. Introduce yourself as the expedition doctor for the “2008 blank blank expedition”.  As long as your name is on the letter, along with a signature from the sponsoring foundation, (such as a friend of yours), custom officials seem to relax.

-Dr. Howard Donner, Chapter One: The Expedition Physician in Expedition & Wilderness Medicine

In addition to medical kit issues, another big problem with border crossing revolves around trying to exit a country with interesting items of question.  Remember that really cool “antique” the local hustler sold you outside the tourist area?  Turns out it’s a stolen artifact from the local museum.  Be wary of buying local valuables that are sold in a surreptitious manner.  At a border it will be you, not the local “entrepreneur,” who will be charged with theft and attempts to export a national heirloom. 

Also, remember that many animal products such as furs or trophies (especially of endangered species) cannot be taken home as well as most alcohol, plants, food items, and some forms of tobacco.  If there’s any question, it’s best not to attempt to transport it.  Just leave it alone and tell stories about “the one that got away” to your friends when you’re home safe and sound.

Even with all the proper documentation and appropriate behavior, frustrating things can still happen when attempting to cross a border.  Some seasoned travelers recommend having a few small "give away" items such as cigarettes, t-shirts of your favorite ball club, small candies, or other light-hearted gift items in your luggage to help sooth escalating tempers.  It's amazing what a small gift accompanied by a smile and a calm demeanor can do to improve a difficult situation.  

If things still go from bad to worse, the best advice is always be respectful, keep your eyes open and your mouth shut, and do not attempt to bluff your way through with threats or angry gestures.  Remember, this is not your home turf, you are not in charge, and you are very much at the mercy of the nearest supervisor in the area.  All your impressive credentials and academic publications won't matter at all to your cellmate in the local jail, and in this situation, Miranda rights certainly do not apply.

Border crossings are a normal part of international travel.  By keeping a few principles in mind, these events can become routine and fun rather than frustrating and frightening.