Physician Writing: Emotional Responses To Breast Cancer

By S David Nathanson MD

Ordinary Miracles: Learning from Breast Cancer Survivors.

Directing a Multidisciplinary Breast Cancer Clinic gave me the opportunity to interact every Thursday morning with newly diagnosed patients, their families and friends, and with my colleagues in Medical Oncology, Radiation Oncology, Nursing, Radiology, Pathology, Genetics, Plastic Surgery, and Psychiatry. I met and observed six new patients every week for years. I noticed that patients, while grateful for the purely technical and medical information, seemed quite interested in the other patients. Patients struggling with their fears of death and the uncertainty of an impending barrage of treatments want to determine how other newly diagnosed patients feel. I wanted to understand these uncertainties, emotions and feelings in order to better manage my patients and to help them cope with their disease. I asked eight hundred of my patients to write about their experiences. I encouraged them to remember the feelings when they were told there was a suspicious lesion in the breast, when they were given the diagnosis in the surgeon’s office, when they faced surgery, chemotherapy, targeted therapy, radiation and follow-up visits. About ten percent of the patients responded to my request, some with brief paragraphs, others with many pages.

A number of common themes emerged from the patients’ stories. There is an emotional value in knowledge gained from professional explanations. Knowledge enabled an understanding of the choices, helped overcome myths, guided decisions, provided hope and diminished fear. All the patients showed an innate wisdom and determination to survive. In taking control of their own treatment decisions and choices they helped unmask the feeling that the disruption to their lives would eventually be overcome, that ‘time would heal the issues.’ During the disrupting events of each of the treatment modalities they found the strength to immerse themselves in ‘normal activities’ which helped them avoid focusing every moment on the cancer. The support provided by family, friends, health care workers, cancer support networks, one’s boss and co-workers were very valuable. Faith in the health team and in ‘a higher power’ played a big role in emotional support although professional psychological help was sometimes necessary. The biggest fears were: loss of control, loss of dignity, pain, loss of a job, and progressive encroachment on personal freedom.

I learned important lessons that enhanced my own ability to manage patients and I was enchanted by stories of great courage, bravery, inner strength and tenacity. I thought that the stories would help many new breast cancer patients, and also their care givers and perhaps many other patients with life-threatening diseases. Organizing the stories into a book was time consuming and filled with joy and it took some time to come up with the title: ‘Ordinary Miracles: Learning from Breast Cancer Survivors.’ Miracles abound in the modern day management of breast cancer and many are related to the creativity of modern scientific discovery, leading to a twenty percent improvement in the overall cure rate of stage one disease over the past thirty years. But the miracle in my title refers to the triumph of the human spirit. Faced with despair and death, the human soul chooses life and hope. No matter how devastated the patient feels when first confronted with the diagnosis, she displays a miraculous and triumphant change within a few weeks while she goes though the necessary treatments. This is an ‘ordinary’ miracle because it is accomplished by almost everyone, old and young, highly educated and less educated, of all social, economic and ethnic classes, and therefore not ‘extra-ordinary.’

Serendipity accounts for the rapid publication of my book. The day after I completed the last page, while wondering how to get it published, I received an email advertisement about a workshop in Boston that offered to address this exact question. I brought the manuscript with me to the workshop, found an editor who liked the work and offered to take it with her to her company in Connecticut. Six weeks later I signed my first book contract. There followed a whirlwind few months of editing, finding a publicist and obtaining endorsements from prominent oncologists, a patient, a theologian, a psychiatrist and a psychotherapist. Soon after the first printing, and while working full-time in my academic position, I was exposed to a number of media interviews including major newspapers, magazines, television and radio. I found myself signing copies of the book at Borders, cancer survivor luncheons and in my office. The most rewarding part of all the frenetic activity associated with the writing and publication was to hear from patients and from nurses that newly diagnosed breast cancer patients felt quite comforted to recognize that they were not alone in their fears. Knowing that someone else had experienced the same feelings and emotions and had survived the treatments was extremely comforting. The learning experience for me and for my patients continues.

About: S. David Nathanson MD, surgical oncologist and Professor of Surgery at Wayne State University Medical School in Detroit is a breast surgeon at Henry Ford Health System in Michigan. He directs A Multidisciplinary Breast Diagnostic Center at West Bloomfield Hospital and the Multidisciplinary Breast Cancer Clinic at the Detroit Campus of Henry Ford Hospital and can be found at www.facebook.com/henryfordpinkyswear and www.youtube.com/user/HenryFordTV.

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For Physicians Transitioning Out of Medicine - How to Keep the Clinical Door Ajar

As important as it is to prepare yourself for your new, non-clinical career - it is just as important to consider what you need if you ever decide you want to go back.

I recently came across a resource for physicians that helps them in the event that they have left clinical medicine and decide they want to return to practice after an extended absence. A website called The Physician Reentry Into The Workforce Project has a wealth of information and resources for doctors considering this career move.

One of the things many physicians fail to appreciate when exploring non-clinical careers is the myriad of things they need to consider in the event that they ever want to go back to clinical medicine. A guide developed by this group includes a 23-page inventory of things to think about before leaving practice, including:

• The financial impact - i.e., costs to maintain the ability to reenter (licensure, credentialing, memberships, certifications, insurance, etc.), educational programs (CMEs) for reentry, etc.
• Professional issues - i.e., the impact of your leave on the practice or organization, communicating with patients / Human Resources about your leave, hospital bylaws about leaves, maintenance of hospital credentials, continuation of malpractice insurance, etc.
• Regulatory issues - maintaining your medical licensure, contacting the state licensing board for assistance, implications for your narcotics registration through the DEA, maintenance of your board certification, etc.

The Physician Reentry into the Workforce Guide also provides a plan for what a physician should do before they leave clinical practice, including advice and tips on:

• Developing a timeline for your leave or reduction of practice
• Making a plan for continuing medical education
• Identifying all practice considerations (i.e., how to inform patients of your leave, facilitating the transfer of care, accessibility of medical records, etc.)
• Maintaining contacts and connections
• Analyzing your financial situation prior to your leave
• Determining the level of clinical practice (if any) that you will keep
• Ways to facilitate your return to clinical medicine while you are on leave (if you so desire) - including advanced planning for your return, clinical activity, CME, personal requirements for return

This guide is free, in a downloadable PDF form found here. Even if you are a physician deciding to leave clinical practice and have no intention of going back, I still suggest you review this guide to ensure you are doing everything required to make your transition into a non-clinical career as smooth as possible… and to cover all those bases in the event of “what if”.

If A Surgeon Can Write A Book or Two, So Can You

If I had only one word, I would use “pinball” to describe my transition from academic surgery as an Associate Professor at Dartmouth to what I do now, combining locum tenens general surgery with being a thought leader in physician engagement and optimizing physician-hospital collaboration.

Yet, writing appears to be the common thread in my iterative life journey.  I learned that the words “author” and “authority” have a common root, auctor, (http://dictionary.reference.com/browse/authority)  meaning writer, progenitor, accepted source of information, power, and mastery.

I had a fortunate break that helped me write my first book, Better Communication for Better Care.  In 2003, the head of the California Hospital Association who heard me present results of a consulting project, remarked, “This is the best work in any California community hospital, bar none,” and told the President of the American College of Healthcare Executives (ACHE) to ask me to teach a seminar there.  As a result of the seminar, the acquisition editor of Health Administration Press, the publishing arm of the ACHE, told me that she had a series of 80-page Executive Essentials books and asked me if my seminar material would fit.

When I said yes, she said, “Just because you have published over 40 articles, don’t think of this project as an extended article.  Writing a book is different.”  What I learned from the process is that:

• Writing a book with a publisher requires others’ assistance: people who cannot abide by others advising them re: title, cover design, length, and word-smithing are better off self-publishing
• The focus is on the needs of the target market: unlike a review article, which is a scholarly product, a book published by Health Administration Press must reflect the unmet needs of senior healthcare leaders, guiding them on what strategies and tactics work with physicians, not telling them how ignorant they are because they did not attend medical school
• Once the book is published, the author’s job begins: at Health Administration Press, a marketing department of two oversees the launch of about 100 books in the catalog; it becomes the author’s responsibility to take an active role in marketing the book if s/he wants to publish another book in the future

So, how do you market your book?

• The Internet is a great equalizer: you can build buzz for your book even before it is published through blogging; I use WordPress because it combines seamlessly with my website (http://healthcarecollaboration.com/blog/)
• LinkedIn (http://www.linkedin.com/in/kencohn) is a great way to connect with fellow healthcare professionals; it also can provide links to your latest blog posts
• I maintain a Facebook page for each of my books, (http://www.facebook.com/pages/Better-Communication-for-Better-Care/98165231327), (http://www.facebook.com/pages/Collaborate-for-Success/114669573209)
• I customize my email signature; my Hotmail account, which has my widest distribution, displays: Author of Better Communication for Better Care: Mastering Physician-Administrator Collaboration (2005) and Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives (2006) http://healthcarecollaboration.com/books

My mentor Sam Horn, taught me, “Ink it when you think it.”  I keep a pad of paper and a pen in my pocket, and on my bedroom nightstand for those moments when a thought comes to me.  Others use the record button of their smart phones to capture ideas.  For me, writing has been a wonderful journey that has expanded my knowledge base and circle of friends and colleagues and that has led to speaking and consulting invitations in 40 states, England, Sweden, Italy, and China.

I hope that your writing journey is equally rewarding and that you will keep me posted on your progress by writing me at ken.cohn@healthcarecollaboration.com

A Physician’s Journey To Social Media & Blogging

By Richard C. Senelick MD

A Physician’s Journey to Social Media and Blogging

A physician’s life often seems to be programmed. We go from college to medical school to internship to residency to fellowship to practice in a seamless path. Twelve to fifteen years go by without too many questions for we are consumed with the educational process and the brass ring at the end of this marathon event. Another straight line seems ahead of us as we pursue our career.

But, are our lives as physician’s really such a straight line or are they influenced by minor events that have major influences on the paths we travel? Life is like a novel where minor or serendipitous events take us in a different direction until another such event pushes us down another path. Most of the major decisions in our lives seem to be made with inadequate information- the decision to marry someone, become a physician, and choose a specialty.  Who really knows what marriage or a particular career will be like?

A Serendipitous Meeting

I had been in practice 35 years, written eight books and produced multiple DVDs. (http://www.richardsenelick.com/books-dvds) I enjoyed lecturing and writing, but again felt that itch to take that little fork in the road that might open new doors and get the creative juices flowing again.  I am a firm believer in reinventing oneself every 5-10 years. I received an email flyer for Dr. Julie Silver’s course at Harvard on “Publishing Books, Memoirs and Other Creative Nonfiction". I can’t tell you exactly why I signed up, but it seemed like a good diversion from the usual meetings on Stroke, Brain Injury and Rehabilitation. I already had a distribution system for my books, wasn’t looking for an agent, but some intangible nagging resonated with that “fork in the road” part of my brain. It was March 2010 and winter had descended on Boston, with winds blowing the snow horizontally. This was perfect weather to settle in for a meeting and avoid the temptation to walk along Newbury Street and sit at a café with my new iPad. I am famous for not being able to sit longer than 2-3 hours at a meeting. So, I took my usual spot in the last row, convenient for the quick escape. What followed were 2 ½ days that became one of those critical forks in the road for me.

Social What?

I was having a great time and getting all kinds of good information on writing, publishing and meeting people, but nothing seemed to be happening that would make a major difference in my career. It is not unusual for me to blow off the last morning of a 2 ½ day meeting, but my curiosity was piqued by a talk on Social Media by Rusty Shelton of Shelton Interactive. I had a “facebook” account I never used, but didn’t have a website, know how to “tweet” and had never commented on a blog, let alone written one. 

I am your typical cynical neurologist, so I sat in the back of the room with my arms folded as Rusty Shelton started his pitch for the new order of social media and publishing. It is not an understatement to say it was a true epiphany and resonated throughout my body. I instantly “got” social media and saw that door that only needed to be opened. It usually took me a year to write a book and then it was only seen by a limited number of people. Even worse that book might be out of date in six months. 
It became clear. My books were meant to educate healthcare professionals, people with disabilities and their families. With a website and a blog I could instantly disseminate information, keep it up to date, communicate with colleagues, people in need and get instant gratification. I also realized that all of my magazines and newspapers were getting thinner and that I was getting 90% of my information from the Internet. I no longer went to the medical school library weekly to sit in the stacks, but the stacks came to me on my computer screen. If I wanted to be part of mainstream society and contribute on an international level the remainder of my life, I had better get on board the social media train or be left at the station.

It is a little less than a year since Julie Silver’s course presented me with a new fork in the road. With Rusty Shelton at my side, we have developed a website, www.richardsenelick.com with books, articles and an active blog. We developed a professional “facebook” page (facebook.com/richardsenelick) and I am even starting to use Twitter. (twitter.com/richardsenelick)  Interviews and other writing opportunities have followed. It wasn’t much later that I received a major opportunity to blog for the Huffington Post (http://www.huffingtonpost.com/richard-c-senelick-md) which has been more fun than I can remember. I have been asked to guest blog on other people’s websites and am getting fully integrated into social media. Not only has it been invigorating, it has allowed me to play a role in the national dialogue that will ultimately impact providers, patients and their families.

No matter what you are thinking of writing, social media and the opportunities it provides should be a major part of your plan. Thanks to Dr. Silver’s course, it is now a major part of mine.

About: Richard C. Senelick MD is a neurologist who serves as the  Medical Director of RIOSA, The Rehabilitation Institute of San Antonio, and Editor in Chief of HealthSouth Press, the publishing arm of one of the nation’s largest hospital systems. He is a frequent lecturer on both a national and international level. Dr. Senelick writes a regular Blog for the Huffington Post.  Amongst his many books and publications, he has authored Living with Stroke: A Guide for Families, Living with Brain Injury: A Guide for Families, The Spinal Cord Injury Handbook, and Beyond Please and Thank You: The Disability Awareness Handbook.

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Bigger Isn't Better; Better is Better

Breaking The Paradigm of Quantity: A Challenge for Physician Leadership

One of my favorite Jackie Mason jokes goes something like this. A potential customer enters a store whose sign in the front window proclaims: "WE SELL NOT JUST BELOW RETAIL.  WE SELL BELOW COST!". He skeptically approaches the store's proprietor and asks, "How can you manage to make a living selling below cost?" "Simple" answers the owner, "We make it up with volume!"

When I tell this joke to  Hospital CEO's or CMO's they laugh until I suggest that they may be doing the same thing with their medical staff strategy: bigger is better. The bigger the medical staff and the bigger their referring volume the better the hospital's bottom line. The bigger the size of a physician's practice the better the quality of the physician. "He/she must be a great doctor, look at the size of his/her practice and how many patients he/she refers!".

This unfortunate strategy has lead to a stampede of practice acquisition, joint ventures, and "institute models" that have, for many, succeeded in bigger referral patterns for hospitals. Unfortunately, few of these bigger systems are actually better. In fact, the acquisition of heterogeneous physician groups with the accompanying variation in practice styles, work ethic, quality and culture have made put further strains on the search for medicine's holy grail: consistent, measurable, efficient and excellent outcomes.

One could argue that this strategy didn't make a lot of sense even when it was embraced in the bygone days of fee for service. It made even less sense when DRG's were introduced and will prove fatal once bundling of all services and ACO's (capitation on steroids) take hold. Organizations that will succeed are those who invest now in developing excellent physician leaders: those who can influence, model and hold others accountable for consistent, measurable, efficient and excellent outcome. This will often require trimming rather than enhancing the number of physicians with admitting privileges.

The winners here will be those systems that recognize bigger isn't better: better is better.

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Physician Stress & Burnout

By Michelle Mudge-Riley DO MHA

Have you wondered about the impact stress and burnout might be having on you? 

Most physicians enter the medical field believing that hard work and dedication will lead to a happy, successful and satisfying career in the practice of medicine. The sacrifices made through the added years of education and training required to develop medical expertise seem to be well worth it in the journey that culminates in a successful career with wealth, stability and a sense of personal accomplishment and altruistic satisfaction. 

Over the past few decades, amidst growing worries about health care costs and quality, the era of external surveillance and accountability grew. Managed care was born and the large number of preventable medical deaths that occur each year as an unintended outcome of medical interventions was highlighted through media and other channels. This was followed by pay for performance and now new legislation with emphasis on Medicare reimbursement rates and prevention. In short, there has been an increase on the external monitoring and interference on doctors, telling us what we can and cannot do and paying us less for doing it.

A recent article in The Annals of Surgery reported that 40 percent of surgeons reported being burned out and 30 percent screened positive for symptoms of depression. Several other peer-reviewed articles suggest that many of these problems may actually begin during medical school and residency training.  One study reported a 50 percent burnout rate in medical students with 10 percent experiencing suicidal thoughts. 

Last year, a survey conducted by The Physician’s Foundation found that 78 percent of physicians think medicine is either “no longer rewarding” or “less rewarding” and 49 percent of primary care physicians say they will reduce the number of patients they see over the next three years.

Physician burnout is more common than it should be. There are a number of steps you can take if you suspect stress and burnout may be affecting you.

Recognize The Symptoms

Many times, physicians don’t perceive that they’re working under any undue stress, and even if they do, they look at stress as being part of the job. You may recognize the more obvious physical symptoms of stress such as chest pain, palpitations, headaches, muscle pains, panic/anxiety attacks, and gastrointestinal distress, but you may not recognize the more subtle symptoms such as anger, irritability, mood swings, apathy, loss of focus, sleep disturbance, isolation, and an overall sense of frustration and dissatisfaction with what you are doing. Understanding, acknowledging and accepting the fact that you are stressed and that the stress is affecting your moods and behaviors opens the door for the next steps.

Remind Yourself This Is Not A Character Weakness

Remind yourself that you are not invincible, that reacting to stress is not a character weakness, and that you can take steps on your own to help adjust to the pressures of the surrounding environment.  Introspection is often involved and includes re-visiting the question of why you became a doctor, what the you enjoy about the profession and what you could do to reenergize the passion in your medical career.

Reach Out To A Mentor Or Physician Coach

Taking advantage of a physician coach or mentor will help provide the needed expertise to move forward. An external “big picture view” from a knowledgeable person with experience in doing this with physicians can help you put things into perspective and create an action plan to move forward.  This can culminate in a desire to change or offer a new perspective on the current situation.  A recent study concluded that physicians who are dissatisfied might greatly benefit from a personal coach or mentor to decrease the chance that the process of burnout will get out of hand.

Diversify Yourself & Your Career

You may want to take steps to innovate and diversify your current model of practice. You could explore opportunities in a field that is complementary to your current field and interests such as informational technology, public health, genomics, or aging. You could pursue more of an administrative role as a medical director.

Some of the options for a physician who wants to use his or her medical knowledge and skills to do more than practice direct clinical care include medical communications and writing, consulting, teaching, starting a business, working in the medical device or pharmaceutical industry, the wellness and health promotion industry, marketing and sales, business development, finance or grant writing.

A physician is uniquely qualified to pursue any of these options but you must take specific steps to move from the clinical to the non-clinical realm. Although physicians make excellent managers, organizational leaders or entrepreneurs, for a physician to step out of the clinical world into any other job requires a shift in focus and some new skills.  In addition, all of these options carry a particular set of job and lifestyle considerations—for example, what is the salary? Are there opportunities to move up the career ladder? What is lifestyle like? Will travel be involved?

It’s important to realize there are options and there is hope.   Exploring sites like this one, finding others and reaching out to those who have been there or who may be doing what you want to do can be an important and empowering first step.

From the following peer-reviewed article:  Rosenstein, Alan and Mudge-Riley, Michelle.  “The Impact of Stress and Burnout on Physician Satisfaction and Behaviors”.  Physician Executive Journal Vol. 36 No.6, Nov-Dec 2010, p.16-23.

About: Michelle Mudge-Riley DO MHA successfully made the transition from clinical practice to non-direct clinical work and now works for a brokerage firm in Richmond, Virginia as Director of Wellness and Health Promotion.

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