Like much of America, I have been spending my leisure time watching “March Madness”.  I have a vested interest.  I learned to love college basketball as an undergraduate at Duke University from 1991-95 which only continued to grow when I returned as a urology resident from 1999 to 2005.  I’m not here to offer analysis as there are far more expert people than me if that is your interest.  However, the unpredictability of the outcome has stirred some connections in my mind that I would like to share.

Caring for patients has several parallels with sports.  I agree with many people that the use of “war” or “battle” analogies when describing patients’ treatment for cancer is seriously flawed.  I would like to consider this metaphor from a different angle which revolves more around the patient-physician relationship than the patients’ relationship to their disease.  What I believe makes college basketball exciting and different from professional sports and even other college sports is that success is heavily dependent on how the team functions together, the extent to which they communicate during the game, and the culture the coach sets for the team.  Sure, a team might have success during the regular season with a superstar player surrounded by average talent but can be outmaneuvered during the tournament by a well coached team that works well together.  For example, Duke has managed to pull off close wins in the last two rounds against excellent teams not because Zion Williamson dominated the game but because the team worked well together and benefitted from Coach K’s expertise. Unfortunately those tight games fell in the opposite direction (Michigan State) in the Elite 8.

Many view this as a tired analogy.  We have heard it over and over again- medicine is a team sport.  Often people are referring to the group of clinicians that must come together to help manage often complex medical issues.  That team is critical and its importance is growing as medical care becomes more complex, our patients’ medical issues are more challenging, and our degree of specialization narrows our focus requiring us to engage others to help.  The core team, however, is the patient and the physician (or provider) and I have had several experiences over the last few weeks that have reminded me of how important this relationship is.  These patients have reminded me, as Jim McKay used to say on “ABCs Wide World of Sports” of the “Thrill of Victory and the Agony of Defeat.”

A few weeks ago, I had one of those rare conversations that remind you of the impact that a physician can make on a patient’s life.  It is easy to get tunnel vision and focus on the problem, the treatment options, the mitigating factors that influence treatment and forget the physical and emotional burden that disease places on the person.  About 5 years ago, I was referred a very active woman with a complex surgical history with chronic kidney disease and a 4 cm renal mass.  Her local physician said because of her prior surgeries that surgical intervention was high risk and he would recommend surveillance.  While she was in her late 60s, she had no other significant medical issues and was the primary caregiver for her grandchild.  At the original visit, we established that she needed to recover quickly and did not want to be on dialysis.  Removing her entire kidney through a flank approach as her local physician suggested as an alternative to surveillance was not an option for her.  She was prepared, educated and asked great questions.  Not to delve into details, I offered her an approach that met her needs and she left the office to discuss this with her family.  Ultimately, we pursued surgery and she did well.

Last week, when she returned for her last surveillance visit with me, she brought her grandchild’s high school graduation pictures from the prior summer to share with me.  She has remained cancer free and her renal function remains stable and because of this, she has been able to continue to nurture and support her family.  She attributes this to the shared decision we made together.

Of course, not every surgery is a complete victory.  Walking out of my clinic, I bumped into one of my patients who I operated on over 10 years ago for bladder cancer and several years after that for a recurrence in the upper urinary tract.  He originally presented to me after being treated for over a year by another urologist.  He came armed with questions and concerns about losing his bladder and quality of life.  We reviewed options together and initially, he was frustrated by my recommendation to remove the bladder.  However after several conversations and a second opinion, we ultimately did pursue a cystectomy and continent diversion.  While he has done great from a functional standpoint and has been able to travel and spend time with his family, he did develop metastatic disease and has had several standard of care and trial treatments that have kept his cancer in check.  He attributes his overall good quality of life to the decisions we made over 10 years ago and while I see him infrequently in clinic, I have had the great fortune to get to know him and his family and my life has been made richer because of this relationship.

And then, there is the agony of defeat.  Defeat can occur in several way in the patient-physician relationship.  Sometimes, like any relationship, the connection is never formed.  Other times, the relationship is soured by poor communication or irreconcilable differences.  Sometimes, the problem is not solvable (or could be better managed by someone else).  Finally, despite everyone’s best effort, sometimes there are bad outcomes.  We all experience our share of victories and good outcomes.  Similarly, the defeat informs us and makes us better doctors and human beings for our future patients.  Recently, I had a very elderly gentleman with locally advanced bladder cancer.  While his intellect was sharp, he had significant cardiac disease and physical limitations that precluded major surgery.  His family has been very involved and we discussed the spectrum of care options from routine endoscopic resection to chemo-radiation to palliative care.  I engaged colleagues in urology, medical oncology, and radiation oncology in the discussion and ultimately we elected chemo-radiation after maximal endoscopic resection.  Unfortunately, treatment has left him with residual disease and a poorly functioning bladder that has led to several hospital admissions for acute kidney injury.  We tried to teach intermittent catheterization but this caused bleeding.  He kept pulling out the catheter we left in place and medications seemed to worsen his cognitive function.  While there is no easy solution, what has made this manageable for all involved is a willingness for me, his family, and him to communicate.  We discuss what is possible and what is not.  I acknowledge where I don’t know the answer and approach his care with humility to ask for advice from colleagues to see if there are other options.  On the other side of the relationship, the family has been engaged and go the extra mile to be proactive about their father’s care.  Ultimately, we have spoken honestly and everyone is realistic about likely outcomes.

There are of course the patient’s where you really neither win nor lose.  A few weeks ago, I saw an elderly but healthy patient for a minor problem.  All the lab tests and images were stable and under normal circumstances, this would have been a quick visit.  In examining the review of systems before walking into the exam room, I noticed that depression and anxiety were checked off on the list.  I have seen this patient for a number of years and they approach life with optimism and a smile.  When I entered the room, I performed an exam and reviewed the results giving them a clean bill of health.  But then I asked about the items she reported on the review of systems.  She explained to me the multiple life stressors that had come at once into her life.  She had no one she could really talk to and very little social support.  I am a urologist and surgeon but I realized what she needed more than anything else, was someone who could listen.  She was not looking for someone to solve her problems or share her burden but only to sit quietly and be there.

As I write this, I realize the common denominator to providing good care whether the outcome is a success or not or somewhere in between is communication and being willing to listen.  I have had the fortune to uncover significant medical problems over the years not because I am the most skilled at physical examination or because I run extra tests but because, like the last patient I described, I am willing to commit the time to listen.  In her case, she was appreciative of just having someone to share with and I was able to connect her with our social worker to provide additional support.  Other times, listening to patients symptoms has allowed me to diagnose diabetes or arrhythmia that have a greater chance of impacting the patient’s life than what they were sent to me for.

The “win” in medical care is often not the outcome.  It is the connection that is made between patient and physician that acknowledges our shared humanity.  Over the past several years, there has been an increased interest to link patient satisfaction to compensation.  Patient satisfaction treats the patient as nothing more than a consumer/customer and physician and health care systems as nothing more than companies delivering a service or product.  As such, patient satisfaction often casts a wide net that can include questions on quality of the food in the hospital, cleanliness of the hospital or clinic, and other items that are not directly related to quality or outcomes.  In fact, there are enough studies out there that show there is a poor correlation between satisfaction and quality of care.

This is because sometimes physicians must make recommendations that patients don’t want to hear or point out problems that are uncomfortable for patients.  Sometimes we have to let patients know that the choices that they have made have resulted in disease and that they must make hard choices to correct course.  Sometimes, I have to say no to requests for medications or treatments that I know will not work or let patients know that the data does not support the choices they are making to treat their disease.  What has helped me bridge the gap between customer and patient is treating everyone like a person and allowing patients to see me as a human being and not just a doctor.

In many ways, I believe this push towards patient satisfaction as a metric may have the same negative impact as the use of “pain” as the “additional vital sign”.  Just like the latter contributed to the use of narcotics to the point of our current crisis, the use of patient satisfaction will drive the investment of resources to improve scores but not necessarily care.  Better food, nicer hospital or exam rooms, and seeing patients within 15 minutes of their appointment may help scores but they do not reflect the true value that a patient may or may not get from an encounter with their healthcare provider.  Of course, CMS argues that they are focusing on how patients EXPERIENCE their care and not satisfaction.  While this sounds nice, I believe the subtlety is lost on stakeholders.  However, questions related to communication and information do get close to what needs to be answered to understand whether patients are actually deriving value from their experience but I believe it is hard to capture the real experience with a survey instrument.  I am honestly worried that the emphasis on the metric will actually detract from a truly meaningful relationship between physician and patient.  While we don’t win “March Madness” with everyone of our patients, working together, communicating and listening, and acknowledging the shared humanity of patient and physician (or provider) allow us to make it further into the bracket than working separately.  I believe that when we emphasize that partnership, we all have a chance to win.

While you might believe that my title is an ode to Christmas, you would be wrong.  In addition, you would be mistaken if you thought I was about to write about the coming of Spring following a cold and miserable Winter in Michigan.  As an academic surgeon who trains residents and fellows, this is the best time of the year because we get to see the fruits of our labor.

Being a faculty member in an academic residency training program is a little like the movie “Groundhog Day” except on a lengthier time frame.  Each year, we welcome new residents into our training program.  They come armed with four years of medical school that has exposed them to the foundations of basic sciences as well as robust clinical exposure across the spectrum of medical care.  In many ways, the medical school curriculum has advanced to include concepts of professionalism, system and practice-based learning, and a better understanding of the broader concepts of health care delivery.  But all this education prepares people variably for the essential transaction that occurs between patient and doctor.  That first day of internship for many young doctors is “shock and awe”.  Translating didactic and practical learning into actual patient decision making can seem overwhelming.  Sure, an intern has their senior resident and attending to guide them but fundamental to any training program is paving the trainees path to independence so that they are prepared to care for their patients.

Each step of the progression for a resident begins the process anew building upon their previous experience.  For example, a surgical intern learns how to care for patients recovering from surgery, readmitted to the hospital, or those with conditions best managed by surgeons.  They also learn who to work with and how to progress care in the complex ecosystem of the hospital and health system.  While they may have had experience with this during medical school, every health system has its unique culture and workflow that an intern needs to grapple with.  The following years are filled with exposure to progressively more complex surgical training, learning how to exercise clinical judgement to help their patients make good decisions, and acquiring additional skills that will help them achieve success in their future careers.

And that is why this is “the most wonderful time of the year” for both faculty, residents, and fellows in a surgical training program.  Much of the hard work of acquiring the skills needed to be competent at a particular level of training have been achieved at this point of the year.  The massive ship of a clinical service runs smoothly with only minor adjustments required.  The rest of the year can be devoted to refining these skills and preparing the resident or fellow for their next step in the process.  Because of my clinical practice, I am exposed to residents mainly at two points during their surgical training.  The first is early on as residents work with me in the OR learning endoscopic/laparoscopic skills.  The second time is during their more senior years where they work with me caring for patients with urologic cancer and learning robotic surgical skills.  Along the way, I have the fortune of working with residents in the hospital caring for inpatients and in my clinic where we focus on evaluation and shared decision-making with patients around the treatment of their condition.  By the last 1/2 to 1/3 of the year, most of our trainees have the fundamentals mastered and we get to transition from “good to great”.

I obviously don’t work in isolation.  Both my faculty colleagues and senior residents have imparted their expertise to residents along the way.  As a teacher, I have come to appreciate that we all have our strengths and weaknesses and I am fortunate that I am faculty in a training program that has skilled educators which complement each other’s strengths.  As such I get to focus on what I am good at which I like to refer to as finishing school.  I expect those who are working with me to be able to cut, tie, and sew.  I also expect that our trainees know about the patient and the steps of the surgical procedure before they participate in a case.  Once I am confident in their abilities, my focus is really helping my residents accomplish three goals.

The first goal is efficiency, not speed.  Every surgery is composed of different steps with different levels of complexity that are connected and feed into the next step.  The goal of a surgeon is not to be fast.  It is to move efficiently through steps of the procedure where immediate risk is low and there is minimal impact to functional or oncological outcomes.  However, a resident or fellow must also recognize when to slow down and take their time when their technique does influence outcomes because of the nature of the tissue or the reason for the step of the procedure.  Overall efficiency comes from knowing when to move with purpose and when to slow down.  It also comes from constantly analyzing the steps of the procedure and understanding what movements and steps don’t add to the progression or outcomes of the case and eliminating them.  Another key component is thinking like a chess player and communicating the next several moves and what is needed to the entire surgical team.  We can’t always guarantee we are working with our usual crew and engaging the entire surgical team by clearly outlining next steps and needs helps everyone to work together efficiently.

The second part is exposure.  Surgical training has changed a great deal over the last 20 years.  Gone are the days where an attending left the room and came in only to perform or assist with the “critical portions of the procedure”.  Our patients expect their surgeon to perform the surgery and I deliver on that promise.  However, we as teaching faculty have an obligation to prepare our residents to go out in the world as safe, compassionate, and skilled surgeons who can make good decisions about whom to operate on (and who to not to) with reproducible outcomes.  This can still be accomplished in our “hands on” training environment and I believe a key component is to have the residents learn to use their retraction and assistants to optimize their surgical view.  For robotic surgeries, the way I have seen many surgeons teach is to hand off particular steps of the surgery under close observation.  Many times, they have already set up the retraction and instructed the bedside assistant so that the resident only has to do the dissection in an already optimized field.  This is not what a resident needs to learn at this time of the year- they already know how to do that.  What they need is to first emulate good exposure and second, be expected to set up their exposure when progressing the case forward.  Learning how to optimize exposure is the fundamental base for safe and efficient surgery that many people do not figure out until several years into practice.

A third component is staying out of trouble.  Of course good exposure keeps you out of trouble to some extent.  But more important is having a strong understanding of the anatomy related to the surgery that is being performed.  If a resident knows the anatomy then they can anticipate where problems may occur and avoid them.  Similarly, knowing the anatomy informs how a surgeon exposes to visualize all the critical elements in a field.  At this time of the year, I expect a resident to articulate how these elements of anatomy are informing their surgical decision making.

My greatest satisfaction is to help my residents/fellows achieve these finishing touches that will allow them to safely and effectively care for their patients as they take their first job or enter fellowship.  But it is not all fun and games because there is one final piece that I try to teach that is somewhat in direct contradiction to how we think of surgical training in this day and age.

The current dogma is that people learn best by reducing the tension in the environment.  I don’t disagree.  It is hard to process information when you are constantly being scolded or yelled at.  But it is hard to argue that surgery is not a high stakes environment and we need to prepare people to perform under pressure.  Our Department was recently given a presentation by the head of security for the health system and his words summarized the critical nature of being able to respond during a crisis.  He of course was talking about a security threat but these words ring true in the operating room as well.  “We don’t rise to the level of our expectations, we fall to the level of our training.” (Archilochus, a Greek lyrical poet)  If we never test how someone performs under pressure, then they will not be prepared when the time arises.  At this time of the year, I try to shift my expectations from teaching skills to teaching performance.  Reading through my previous resident evaluations, I feel that some of my former trainees appreciated this.  I also have received feedback that former trainees have heard my voice in their head that has helped them deal with challenging circumstances.  While I am not a sadist, I take great pleasure is seeing trainees rise to expectations because I know their patients will be well cared for and they will have the confidence to be successful.

This experience is not unique to medicine.  Other professions have the great privilege of seeing their student, apprentice, or trainee transform over the course of their education.  The rest of the year is not so bad but being able to transmit hard earned lessons from my experience to a resident who can now understand is a true joy.  It means they will be better equipped than I was to tackle that next step.  I continue to work hard and learn every day but my hope is that I will help those around me be better.  It truly is the “most wonderful time of the year”.

 

I’m just going to come out and say it.  I believe that the concept of “Medicare for All” is populist rhetoric aimed at engaging the very progressive and left leaning base.  In the next several paragraphs I will try to explain (my opinion) why this type of populism takes us further from securing the health and wellbeing of America.    

Populism is a political movement that claims to represent the “will of the people”.  Populism is on the rise globally and it is not isolated to either end of the political spectrum but lives on both extremes speaking for those who feel disenfranchised from the mainstream.  The United States has a long history of populism.  One interesting example of populism that is applicable to our current discussion is the rise of the “Tea Party” movement.  The Tea Party rose up following the election of Barack Obama around 2009 at least in part as a reaction to the Affordable Care Act.  Although there is not a unified political platform, politicians who arose out of the Tea Party movement in general opposed universal healthcare, supported lower taxes, smaller government, and increased fiscal responsibility.  The success of this movement came from grassroots support at the local level with an underlying distrust of the Obama Administration. 

The support for “Medicare for All” has a similar feel to the Tea Party movement albeit on the other side of the political spectrum.  It seems like a reaction to the current administration’s efforts to undermine the Affordable Care Act.  Just like the Tea Party shifted the Republican Party more to the right, the progressive movement advocating for environmental and economic justice is shifting the Democratic Party further to the left. Like the populism of our history, there are good elements to the arguments.  Prior populist movements responded to inequity and unfair advantage held by certain groups over others (such as supporting anti-trust movements or women’s right to vote) and our current circumstances reflect an even greater inequality in this country that translates into decreased opportunity for many based on socioeconomic status.  The progressive element of the Democratic party and the wave of newly elected officials to Congress, State, and local government are unmasking the illusion of meritocracy in this country that we need to grapple with if we want all Americans to have an opportunity to succeed and contribute in our nation. 

But also like the other populist movements, there is a negative aspect to the rhetoric.  The current discussion of “Medicare for All”  is less about race or national identity and more about an economic divide that casts those who are financially successful as morally inferior.  There seems little distinction between those who obtained their wealth by inheritance and those who are achieving success through hard work and innovation.  As a doctor, this concerns me.  First, I was not born to wealthy people and while I was lucky that my family emphasized education, I obtained loans for college and medical school which I continue to pay many years after completing my education.  While I am well off and can provide for my family, I do this through working long hours having sacrificed at least a decade of my life as a low paid resident and fellow working even longer hours than I do now.  Like many of my friends, I have pursued academic medicine which has allowed me to care for complex patients best served by the resources and skill of my institution, educate our future doctors who will care for people in the community, and contribute to the advancement of medical science through innovation.  While I make less than my colleagues who chose non-academic careers, my life is rich and each of my days brings me new challenges.  Progressives will argue that I have benefited from the labor of others that have contributed to my success and I won’t argue that.  But does my hard work and success make me the bad person? 

This is the fundamental problem with a policy like “Medicare for All”.  It is not really being put out there as a reasonable solution but as a tool to divide and polarize people politically.  I don’t think anyone would argue that people are entitled to health and wellbeing as a right.  But I disagree that healthcare as we currently define the services provided under Medicare is a universal right.  In my experience, medical issues tend to break down into two categories.  The first are medical issues that occur for the most part out of no fault of our own.  We can quibble on the details but many childhood illnesses fit this bill as well as diseases in any age group that have no apparent etiology or caused by infection.  Similarly, people injured by crime, accidents, or other circumstances in general did not bring medical misfortune upon themselves.  The other large category is disease that we bring on ourselves.  This occurs by choices we make in diet, exercise, drug/tobacco/alcohol consumption that lead to changes in our body systems and organs that result in disease.  If we provide universal healthcare coverage to everyone, we are saying that people are not accountable for the choices that they make that affect their health and wellbeing.  This means that a person who does make good choices in terms of diet, exercise, sleep, alcohol consumption, tobacco or other drug use bears the same cost as someone who chose not to care for themselves. 

Defining how an individual should behave and how that influences their medical coverage is not a government decision.  We as individuals in a free society should have the ability to make choices that may not be in the interest of our health and wellbeing.  However, we as taxpayers should not necessarily have to bear the cost of others’ bad decisions.  That being said, even when we think people are making individual choices, there are outside influences that impact their health and wellbeing.  Issues of clean water, access to healthy/fresh food, clean air, safe housing and neighborhoods, parks and public spaces to recreate in, and availability of preventative services (vaccines, screening) have a much greater impact on the health and wellbeing of a population than any doctor or “Medicare for All”.  It is hard for anyone to argue that we, the people, do not have a right to these basic resources and it seems like these issues are within the purview of local, state, and national government to secure these through allocation of our taxes, zoning, and other policy. 

But let’s play devil’s advocate for a moment.  Let’s say that we could somehow get our politically divided nation to agree to universal healthcare and a single payer system such as “Medicare for All”.  Let’s assume that everyone would agree to raising enough taxes to fund the enormous cost of providing universal healthcare.  Do we really believe that a single centralized payer is the best way to allocate resources?  Are we confident that resources will be distributed equitably and efficiently and that will translate into improved health and wellbeing of all Americans?  Supporters of universal coverage point to most other developed nations as the rationale for this policy.  But the truth is that very few countries actually have a centralized single payer.  I’m no expert on this but in my brief review, the solutions for universal coverage range from a single payer to employer mandated coverage (Switzerland) to local collection and allocation of taxes to support healthcare (Denmark).  While Medicare is a single payer for our population over 65 years old ( and other select populations), it is accompanied by multiple third parties that provide supplemental insurance, prior authorization, review of reimbursement for hospitals and physicians, compliance oversight, funding for graduate medical education, and a myriad of other factors that make this a bureaucratic monolith.  Adding everyone on to this program is not a simple matter of expanding the existing infrastructure but would exponentially increase the complexity of an already complicated and inefficient structure. 

The last argument I want to make relates to my role as a doctor.  We as doctors have benefited from Medicare and support of medical science by the federal government.  Despite the fears of the Affordable Care Act, we as doctors and other healthcare providers have had the ability to care for patients that previously would not have had access to care either through the insurance exchanges or expansion of Medicaid at the individual state level.  Of course, this has not been a free lunch for physicians or Health Systems as I discussed in my last blog.  It has been accompanied by a tremendous increase in regulatory and clinical oversight, barriers to delivering care through prior authorization, narrow networks, and payment structures based on hitting metrics or adhering to guidelines.  This is a messy time to be in healthcare delivery but the one upside is that it has got everyone thinking about how our fragmented system can best deliver value-based care.  The efforts of all stakeholders as they attempt to grapple with the new world order are actually real time experiments that we can study to understand what is and is not working well in health care delivery. 

I am concerned that if we moved to a single payer model, that we would lose this innovation in two ways.  First, there is no impetus for a single payer to run any experiment.  They can set the reimbursement for a service that encourages certain services being provided and discourages others.  As such, the incentive for those who deliver healthcare to innovate goes away.  Sure, there will be an effort at reducing costs for health systems to maintain their margin but this is only one aspect of innovation in healthcare delivery and ignores the advancement in medical science that takes place at a rapid pace.  Medicare does have the CMMI, ACO, and other programs but I would argue that they do this because of their role in helping direct care for other payers or cost reduction and in the absence of other players in the market, that role would go away. 

Second, a system that is designed to deliver health care services to all will naturally need to constrain choice, choose what to cover, and ultimately ration healthcare to contain costs (especially when we do not address the root cause of our health problems).  Naturally, with less financial and innovative opportunity, talented people will choose to invest their efforts elsewhere.  People who would have pursued a career as a doctor, physician assistant, nurse practitioner, nurse, pharmacist, or other healthcare professional might choose to invest their efforts elsewhere.  We already have a shortage of clinicians in our country especially in rural areas and this could exacerbate this crisis.  In addition, people and companies that are interested in scientific innovation might look for other opportunities rather than developing the next drug or device to improve care.  This won’t happen immediately but will erode what we value about our flawed system over the long term. 

There are, of course, many more arguments that can be made against universal healthcare and a single payer and there have been much more expert articles written on this topic than mine.  My point is that if we want to do something meaningful regarding the health and wellbeing of our fellow Americans, we need to stop kicking around healthcare like a populist football.  Whether it is the left advocating for universal coverage that is too costly and not supported by many who are happy with their coverage or the right who want to tear down any government supported safety net, the arguments being made are talking points and not real solutions.  I don’t have an easy solution but I do have thoughts that I want to summarize.  I believe our government’s best efforts are placed not in being the sole payer of healthcare (through our tax dollars) but by finding solutions that address the social determinants that negatively impact health especially for those who are most vulnerable in our society.  These issues impact everyone regardless of political identity.  Second, while the Affordable Care Act is flawed, it has encouraged stakeholders to innovate in how we care for populations.  This is also true for Medicaid expansion where states like Michigan have demonstrated real outcomes benefits for their programs.  Shifting the discussion from the federal government to the state and local level could allow for solutions that meet the unique needs of local populations by people who are more directly accountable to their constituents.  I would argue that we need to “double down” on aspects of our healthcare delivery that encourage innovation both to improve the value of the care we currently deliver and identify better ways to work together to deliver it for the future. 

I know my argument is flawed so please share your feelings with me and those reading this.  I hope I can stimulate a meaningful discussion on how to deliver better health for all of us and not people sticking to political talking points.  Thank you. 

For this blog, I wanted to run a thought experiment.  Like everyone else, the issues of physician burnout and well-being have been weighing on my mind.  There is so much that has been written about this but based on what I have seen, the discussion tends to fall into three buckets.  The first bucket, from a physician perspective, is that of exit strategies.  The argument assumes that the situation will only get worse and so it is in the best interest of those who can to find alternatives to their chosen career.  The second bucket comes from “the organization” where the discussion centers around the risk of burnout in terms of patient safety and quality and how to stabilize the physician work force so that they are productive and safe.  Sitting in between these buckets, is the academic bucket that seeks to understand not only the signs and symptoms of burnout but countermeasures to combat it. 

To me, this is the fundamental challenge.  We have not gone any further than countermeasures to address a problem that is decreasing the wellbeing of an already strained workforce.  People point to the electronic medical record as the source for burnout. At my institution, efforts have focused on scribes, classes, and other tools to help make physicians more facile with the system so they spend less time outside of clinic documenting and completing clinical tasks. But this is just one aspect of the “burnout” picture.  Issues of work-life balance brought on by changes in priority of the physician work-force (and generational differences), lack of meaningful time to pursue other aspects of our careers, increased expectations from the organization, payers, and patients, barriers to delivering care by regulations, guidelines, insurance policies, and resource constraints are just the tip of the iceberg in terms of contributors to “burnout”.  Similarly, wellness officers have only scratched the surface when it comes to addressing these issues- resilience training, templates that include slots for charting, mindfulness, physician lunches, recognition are in my humble opinion window dressing to tackle the problem. 

The tension between physicians and health systems is an age old professional struggle.  It is the conflict between the physicians need for autonomy and the health systems need for efficiency, productivity, and growth to continue to fund the clinical enterprise.  What has fueled this to the point of burnout being an epidemic is how rapidly physicians have transitioned from small business owners to employees giving up their autonomy.  A non-employed physician would previously use the hospital as a resource and the administration would view good clinicians as customers that provide their patients good services.  Currently, physicians (their salaries) are viewed as losses on the P&L and productivity is the only way to balance the cost. 

The prisoner’s dilemma is an example of game theory to help explain how individuals or groups might cooperate in a particular circumstance.  In the classic experiment, two people are brought in and charged for a crime.  There is enough evidence to convict both on a lower level crime but they believe they are responsible for something worse.  They are each separated from one another so that they cannot cooperate.  If the two people remain quiet, they both receive the lower penalty.  If one of them betrays the other but one remains silent, one person walks free while the other gets the maximal penalty.  Finally, if they both betray each other, they both get the maximal sentence.  The scenario is set up for people to select the self-interested choice because this gives them an opportunity to walk away.  Assumptions built into this model are that there is no downstream consequence to the action of betrayal.  Interestingly, the data suggests that there is a bias towards cooperation which seems to maximize the utility of both individuals. 

In my search of the literature, I actually found very few scholarly articles applying the prisoner’s dilemma to health care and most of it was focused on the patient-physician relationship.  None of the studies or other writing I found on this model examined how the prisoner’s dilemma would apply to the relationship between physicians (or other employed clinicians) and healthcare systems (the employer).  So let’s try to run the model. 

First, we must understand the charge we as physicians and our academic healthcare employers are facing. The lesser charge is operating under a fee for service model that encourages clinical activity as healthcare tries to transition to value based care. To simplify this discussion, I want to focus on the employed physician model since it is rapidly becoming the most dominant model.

In the first scenario, the hospitals ratchet up demand while doctors remain silent. This is largely accomplished by carrots and sticks. More RVUs mean greater financial rewards while failure to comply with increasing expectations around clinical productivity, timely documentation, access, patient satisfaction, national quality measures, and a laundry list of other requirements puts the doctors financial and resource wellbeing at risk. This is the heart of the burnout issue as it attacks the autonomy of the physicians time and decision making. While health systems argue that margin supports mission, the need to fuel growth can seem like a treadmill that has no end. Because the goal is unclear, buy in from physicians and other members of the healthcare team is forced by carrots and sticks rather than believed. Ultimately this perpetuates the crime of the productivity model and leads to backlash.

The backlash is where physicians and other who deliver care hold health systems hostage. While physicians as a group do this poorly, there are scenarios where physicians placing the blame on health systems can have a negative impact. I’ve already mentioned one strategy above- physicians leaving medicine altogether. This is a bigger cost than the lost FTE. It is the cost of the years of investment to train that individual. More subtle is the choice of decreased productivity that physicians are making in the interest of work-life balance. While this might help burnout, health systems incur high fixed costs of recruitment and benefits to bring in additional supplemental FTEs. In addition, it is unclear how “part time”physicians perform from a quality standpoint- does it just take longer or do they ever achieve the level of clinical expertise as a full time clinician. Is this part time model even possible for some specialties where clinical demands and patient expectations do not fit neatly into 36 hours/week?

There are other ways that physicians place the blame. In the most dramatic scenarios, health systems have been subjected to the loss of entire service lines leaving a hole in clinical expertise that ripples through the system. For smaller systems without a deep bench, even the loss of a single physician can have an impact as employed physicians become mercenaries willing to move for a better RVU rate or income guarantee when their contract is over. In fact, many physicians have entered the “gig economy” providing locums services at high cost to systems who must pay more than salary to bring physicians in on a temporary basis (housing, licensing, malpractice,etc). For less common and high need specialties, this mercenary approach is costing healthcare dearly.

More subtle but no less problematic is the literal adherence that some physicians take to their contract. Call coverage, providing care at new sites built or purchased by a health system can be ways in which physicians leverage better pay for very strict adherence to the wording of a contract. In academics, this plays out as the percent effort. Even in the setting of acute clinical need, funded physician scientists may block days on their schedule based on time that is really only partially funded by grants or other sources. True, they may get penalized for decrease productivity but the excess work merely gets transferred to less funded more clinical colleagues.

When physicians and systems both blame each other, the real loser is the patient. Our greater crime is that we have focused on throughput over the health and wellbeing of our patients. We all understand that the healthcare model is transitioning to value based care but we are all trying to grab what we can until we get there. In the circumstance where both physicians and health systems turn on each other, ultimately we have a complete breakdown of culture. Patients can sense this immediately and in markets where patients have choices shy away from systems where animosity runs high.

Which leads back full-circle to where we started. In the prisoners dilemma, the scenario in which both parties keep silent results in a lighter sentence for both minimizing the losses of both. In our healthcare model, cooperation requires both physicians and health care systems to give up something in both groups’ interest and more importantly in the interest of patient care. I believe that many systems have taken this cooperative approach by becoming clinician run organizations and this helps to an extent. The problem no matter how much you try as a physician leader to remain engaged is that you rely on an increasingly narrow and sometimes distant experience to provide insight on the administrative level. This is easier for physician leaders who maintain some clinical practice. However, the further a clinician gets from clinical care, the more likely they are to rely on numbers that can be taken out of context.

Is there a solution? I believe there is. We have models that already exist to guide us. The idea of a salaried model with minimal to no incentive would allow physicians to focus on a practice that is high value and patient-centered over productivity. Health systems would somehow need to make this worth it by providing physicians pensions or by incentivizing people with time for other activities. Physicians would need to give up individual autonomy but embrace the transition to leadership of the clinical team rather the lone wolf model we were trained in. Collaborative practices in which responsibility sat with a person based on their license and expertise allows everyone to focus on what they are trained for. There is no doubt that systems would have some decrease in productivity in the current model but it would prepare them well for the value based care model of the future that would allow physicians to engage in activities that benefit patients without worrying about the RVUs it might generate.

There are problems with this model. Lack of incentives will result in some either leaving to pursue economic fortune elsewhere as salaries would likely need to reflect lower productivity. Other may use this as an opportunity to fly below the radar and try to do no more than necessary. While some would argue that the lack of incentive discourages innovation, I would argue with the right culture, the model could be liberating allowing clinicians to focus more on health and wellbeing over throughput.

The other cooperative model would be for employers to become owners. I think back to the Saturn car commercials of the 1980s that showed a highly motivated work force because they owned part of the company. There is nothing like shared financial risk to bring groups together. If you allowed every employee of a health system to place some of their salary at risk each year and either share in the margin if it is positive or take a financial loss if negative, this could encourage cooperation. Those who wanted no risk could opt out but I suspect the majority would choose to participate. I can only imagine that this violates some laws and for those who are smarter on these topics, let me know. But I could envision a situation where everyone would be interested in conserving resources, designing processes that manage patients in lower cost settings, etc. Here the cooperations minimizes risk to both parties while offering the potential for an upside.

I would really like to learn your thoughts. There is no easy answer but I have become convinced that while we are all prisoners in a complicated system, there is a way out and that requires doctors and other healthcare providers to collaborate with the health system in the interest of patients’ health and wellbeing. Our models of blame do not work and while cooperation will still require sacrifice, it will be better for us, the system, and our patients in the end.

Imagine starting a new job with very little orientation, on the busiest service (cardiac surgery), with minimal supervision from a disgruntled cardiac surgery fellow (who barked instructions while speed walking through morning rounds), and knowing that you would be in the hospital at least 36 hours from the time you walked in the door because you were on call.  My worst fears as an intern were realized that day.  After he left to go to the operating room for the day, I looked at my list and realized I did not know how to accomplish 1/2 the things that were on it.  I felt like I was doomed to failure and would be looking for a new job the following day. 

I also knew that first impressions mean a lot in the world of medicine and that failure to accomplish the tasks at hand would be viewed as a sign of weakness.  If I had the label of weak and incompetent attached to me early on, I might make it through training, but I would not be given the same opportunity as those who were viewed as capable and strong.  I was in a bad place. 

However, it was not a place that I was unfamiliar with and I suspect it is a common experience for anyone reading this who completed surgical training or rose up the ranks in any high pressured field.   You would think that medical school would prepare you for the rigors of internship.  While I felt confident about my medical knowledge (misplaced confidence), I had very little knowledge of how to get things done in my new environment.  Every service, hospital ward, Department, etc… is its own micro-environment with its own way of doing things and its own set of rules.  Fortunately, successful medical students are very familiar with this.  Every 1-3 months as a medical student, you rotate to a new service and  learn the unspoken dynamics between the attendings, residents, nurses, and other medical staff.  You learn what drives the culture of the group.  And you learn to exploit it to be successful in that environment. 

And that is exactly what I did on my first day.  I quickly went down my list and accomplished the easiest, most straightforward tasks.  Along the way, I began to get a lay of the land.  I was friendly and spoke to anyone who would speak to me.  As I started putting charts with orders into the chart box, I struck gold with the Unit Clerk.  She had worked there for over 30 years and could have been my grandmother.  And being a young looking 25 year-old, she treated me like her grandson. 

She told me to sit down and for the next 30 minutes described how the morning, middle of the day, and afternoon/evening worked for the cardiac service.  She told me all the tasks that were supposed to happen early on (check labs, write orders, write notes), when to pull the chest tubes, who to talk to in radiology to get my x-rays done first, when each attending surgeon would come up to the floor and round and whether they wanted me to walk around with them or wait until they were done to see what they wanted for their patients.  She told me how to prioritize discharges and who to talk to if I was having trouble getting patients out. 

It was like a fly wheel.  Once I started acting on her advice  and patient care was moving forward, other people began to help.  The nurses would bring the charts to me to write orders, the social worker paged me and helped me deal with a difficult discharge.  The pharmacist helped me make adjustments to a TPN order.  I might not have had a chance to go to the bathroom or eat something, but by the time my fellow came up to round in the evening, I had accomplished all the tasks set out in front of me.  I felt that I had achieved success!

Well my feelings of success were completely crushed as we rounded on each patient and my fellow yelled at me for either not doing something or making an incorrect decision (based on his view).  By the end of rounds, I had the same sized “to do” list as I had in the morning to accomplish by the following morning when we would do it all over again.  I started to frantically go down my list and get things done- draw labs, track down x-rays and records for surgery the next day, write orders, and check on patients who needed extra attention.  Half-way through this, I began to get sign out from interns on the thoracic and other cardiac service (transplant) which only added to my list.  To add to this, I began getting pages from nurses asking me to respond to atrial fibrillation, constipation, diarrhea, pain, delirium, and a laundry list of other issues that seem to rear their ugly head when the sun goes down. 

I survived that night (and so did my patients) through hard work, sheer determination, a little luck, and being as nice as I could to anyone I came across that might help me at the time or later.  It worked.  I survived that night, the next day, month, year, and subsequent transitions in my career using the same tools I learned in medical school and residency.  People around me have come to expect that I am willing to work hard, not complain, try to be nice, willing to help my friends, family and colleagues, and often prioritize organizational goals above my own.   

In general, most people would say these are good characteristics to have.  But every silver lining has a cloud.  The problem is that people assume that this is who you are, expect that you will always behave in a certain way, and react when you do not perform in a way they expect.  Most of us go along with these expectations because these behaviors have been the secret to our past success.  In acting, they call this being “type cast”.  Actors are given the same roles to play over and over again because they do well with them and fellow actors, directors, and the public associate them with a particular type of character.  We can all think of actors that fit this bill. 

Similarly, I believe if we all stopped and reflected that we, like actors, are type cast into a particular role, a certain set of behaviors, and defined expectations.  As time goes on, we adopt that role as our true self.  It may be who we are but it leaves little room for who else we may be as well.  If you have had unconscious bias training, you might be thinking about this discussion in that context.  The difference here is that being type cast requires both others and ourselves to make assumptions about us.  Unconscious bias often takes place when we encounter people we don’t know but make assumptions about them based on how they look, behave, speak, and any number of cues.  Type casting is a bias that develops that is shared by those who know us and our own self.  But just like an actor who is type cast, living a type cast life has drawbacks. 

I have come to understand that being type cast in our lives has several drawbacks.  The tools and behavior that help us to perform well in certain environments may not be effective or may even be counterproductive in other environments.  The most dramatic example of this is soldiers returning home from war.  The behaviors that keep people alive during combat are not conducive to family life.  Similarly, the behaviors that make someone a good intern do not necessarily make somebody a good parent, spouse, or partner.  It can be challenging to transition back and forth between different social expectations.  A great deal has been written on this subject and I will not pretend to be an expert.  From a career perspective, the behaviors that make us successful professionals do not necessarily prepare us to assume leadership or other roles as we evolve in our careers. 

On a more personal level, being type cast can cause emotional and physical harm.  The expectations and social norms of those around us that we take on as our own, may not be true to ourselves.  Fortunately, our world is changing but not fast enough to prevent some from suffering under the yoke of these expectations.  Again I am no expert here and I am fortunate that I have not had to live a lie.  But many people continue to do just that.  They are forced and accept the lie of sexual orientation, gender identity, body image, career direction, love, ideology, oppression, physical restrictions and countless other social and cultural norms that tear at some peoples’ souls to the breaking point.  Living these lies can make people mentally and physically ill.  While I accept that there are certain societal boundaries and cultural norms that we need to live within to coexist with each other, I believe that at least here in the United States that the ideas outlined in the Declaration of Independence of life, liberty, and the pursuit of happiness should be provided to all of us and we should all aspire to help our fellow human beings live in a world where this is possible.   

I want to mention one more point although I am sure there are other reasons why type casting in our lives is harmful.  The roles that we assume to function and thrive in a particular environment limit our possibilities.  This is not merely the possibility of career development/advancement that I discussed above.  This is the type casting that prevents us from exploring other roles, other aspects of who we are and who we may want to be.  This point is interrelated to my first two points.  The limitation on our horizons begins early in life as those around us define our opportunities, strengths, and weakness and we integrate these into the fabric of who we are.  Our lane becomes defined and over time as we adhere to this lane, it becomes narrower and straighter.  The potential societal cost to this is huge.  When we fail to provide others the space to explore who they are and what drives them, we may miss the next scientist who will help us establish human life on Mars, or a great teacher, doctor, parent, or friend.  We lose the next best song, novel, or poem.  Poverty, injustice, and social determinants likely have a greater impact on missed potential but providing people space to explore is much lower hanging fruit to fix that might give our society the next scientist or leader that will help us solve a major challenge.    

The first step in tackling this is for all of us to acknowledge that this exists.  A phrase that is driving me crazy right now is, “Stay in your lane, bro.”  Its problematic for two reasons.  Not only is it a nice way to say shut up and mind your own business, it also has the implication that people need to stick to a particular path.  The second step to addressing your life if you feel like you have been type cast is to do something about your lane.  You don’t necessarily need to change lanes and risk crashing into somebody else but you can work to expand your lane, take the next exit off the highway and take the back roads, or change lanes if that is what you need to do.  You can even make a U-turn and change directions.  For me, writing this blog is an element of changing lanes.  I feel very fortunate that I have a life of meaning where I help to alleviate suffering and treat cancer.  But this blog gives me an opportunity to do something for myself.  If nobody reads this, that would be just fine with me because writing this has given me the chance to explore outside of my lane. 

Some of you reading this might think that you are not type cast and you may be right.  The test question to ask yourself is how often you feel guilty or anxious about not doing something or performing in a certain way.  If your answer is rare, you are probably in pretty good shape.  If your answer is often, then you may be type cast in your role in life.  While it is true that my family very effectively used guilt to set expectations, if you’re grown up now, you need to overcome these chains.  If you are a physician/clinician, our roles are increasingly being type cast.  Expectations and pressures to perform and function in a certain lane are coming from both the lanes around us and oncoming traffic.  The data on patient satisfaction is mixed but organizations and payers are increasingly tying compensation to these measures.  Our job as clinicians is to keep people safe, heal them (or alleviate suffering) and be nice to them in that order.  It is not to give them want they want especially when it is contrary to scientific evidence or best practices.  Forcing clinicians to perform this role is bad for us and our patients.  I have fought this role by having honest conversations with patients and setting reasonable boundaries to what I am willing to offer.  Patients should have education and choice when it comes to their treatment but my clinic is not Burger King; I don’t have to do it your way. 

I want to leave you with an excerpt that I believe summarizes my discussion much more eloquently than I can.  As Jacques spoke in William Shakespeare’s “As You Like It”:  All the world’s a stage, And all the men and women merely players; They have their exits and their entrances; And one man in his time plays many parts…

This post is not a treatise on mentorship.  There has been a great deal of thoughtful research and commentary on the value of mentorship to support people as they progress through their personal and professional life.  Instead, I wanted to share with you my personal thoughts and experience with the concept of mentorship.  I hope if you read this that you will share your personal experiences with me and others regarding mentorship.

To sum up my experience with mentorship, I would simply tell you that I cannot point to a single individual that has helped guide me on my path of professional or personal development.  I can identify individuals who have trained me, inspired me, offered me advice, and been role models.  Each of these contain aspects of mentorship but my personal belief is that a mentor-mentee relationship typically incorporates all of these aspects in a one-on-one relationship. Sometimes the one being mentored has a small group of people to help guide them on their path (mentorship committee).  More importantly, I believe a mentor provides critical feedback (tells you what you don’t want to hear) and also guides you in what not to do helping you to avoid taking on activities that would be counterproductive to your ultimate success.  This blocking and tackling of obstacles represents the greatest value of mentorship. 

Many reading this will ask what about my parents?  As a son and now as a parent of three, I would argue that parenting goes above and beyond the responsibility of mentoring.  When I think of a mentor, I think back to a handful of teachers that nurtured and developed my interests and were there to help me when I made a wrong turn (maybe I did have a mentor early on?).  But as a parent, I believe my role is so much more.  It is not to guide them in the right direction down a single path but to give them ample opportunity to choose the path that will fulfill them.  It is not to run interference but to understand when you need to let your child try and fail and when you need to intervene.  It is not to only help them achieve their goals, but to keep them safe, healthy, and provide them with a moral framework so they can achieve their dreams.  My parents gave me all that and more and their role in my life cannot be compared to mentorship. 

But getting back to my point about mentorship, this is not a story about a failure of people or the system around me to provide me mentorship.  This is also not a story of “if only”.  I overall am satisfied with my life and career.  While I am not in the place I would have anticipated almost 14 years ago when I finished my fellowship, I have a robust clinical practice and have had the opportunity to take on leadership, operational, and administrative roles where I have learned, been able to make a meaningful impact, and enjoy doing.  More importantly I have a wonderful family that brings meaning and joy to my life every day. 

Most discussions on mentorship focus on the mentor and how to do it well but I want to focus on the mentee (I am using this but not sure this is a real word so forgive me if it is not).  Specifically, I want to focus on my experience as a mentee.  To do this, I want to share two stories.  From about the age of 5 until 11 years old, I grew up in central Florida and our family’s primary activity was playing tennis.  I remember hanging out at the public tennis court with my brother and parents for what seemed like many hours on the weekend.  My dad, who is a mechanical engineer approached the game as you might expect a technically minded person to approach any physical and technical challenge.  He read books, took lessons, and watched all the tournaments televised at the time (pre-Tennis Channel or on demand video) identifying aspects of McEnroe, Conner, or Bjorg’s strokes, serve, etc… that he could incorporate into his game.  His expectation was that my brother and I would do the same.  My brother being the first child rose to the challenge accepting my Dad’s and his coaches mentorship.  He was ranked for a time and achieved success on his High School tennis teams. 

I on the other hand, had lackluster success. I did play on my High School tennis team for a short time but for anyone who has experienced this, I was always number eight on the team and at risk from challenge from the lower ranked players on the team.  At the time, I attributed my lack of success as being left-handed in a right-handed world and the failure of coaches to translate their teaching to my right-sided brain.  In addition, I acknowledged that I was not physically the most gifted athlete.  I’m relatively short and not terribly coordinated.  Both of these factors contributed to my lack of stardom but the real reason, in retrospect, rested in my own behavior and personality.  As a kid, I hated criticism (I was my own worse critic and found it difficult to take critique from others) and had a hard time taking advice.  While I put up a passive-aggressive front with my coaches, I simply defied any advice from my father. 

Fortunately, this did not affect my success in other areas.  When it came to school or theatre/debate (which I transitioned to with my fizzling tennis career), I simply spent hours trying to figure it out on my own.  It wasn’t until my early 20s when I saw that my inability to accept criticism and advice was impacting my personal relationships and goals that I consciously made a change.  Like many things in my life, I had to figure this out on my own.  I taught myself not to react when being criticized or corrected.  I would write down advice or critique that others gave me and review it later in private and determine which information to act upon and what I would choose to file for later.  And ultimately I made the transition to seeking advice and guidance.  I would reach out and ask critical questions to people who had expertise to try and improve. 

It’s not perfect.  As you can tell, this acceptance of criticism and advice is on my terms.  I am not an open book but rather a password protected site open to only those I choose to let in.  But it’s better and I believe that having insight into this aspect of my character, is a big leap forward.  Which brings me to my second story.  About 6 years ago, I took on an operational role.  I don’t want to go into details to protect the names of the innocent but suffice it to say that I had a lot of energy and motivation, but a significant amount of inexperience.  But again, I recognized my weakness and reached out to a handful of people to try and get advice and guidance.  One individual that I reached out to was a very senior person in the organization who was also one of the most challenging people to deal with in the leadership space I now occupied.  In addition, I was offered my role over his protégé which made me even more suspect to him. 

I set up a meeting and went to his office with a list of questions.  After we had exchanged the typical niceties, I pulled out my list of questions and asked him if I could ask him questions and would he be willing to serve as a mentor.  At the time, his answered shocked me but in retrospect it should not have.  He stopped me and asked that if he took the time to give me advice and act as a mentor, would I follow his recommendations.  I answered honestly, no, I would not always follow his advice.  He told me that if I did not follow his advice, then he would not mentor me and asked me to leave which I did. 

At first this seems appalling but looking back, I can see his point.  My point as a new leader was to try and win him over.  While I certainly would have been appreciative of his advice, I would have used it selectively as I have taught myself to do over the years.  As such, he did not view me as a worthwhile investment of his time and effort.  While another person might have taken this as an opportunity to influence a young leader, he preferred to remain separate knowing that he could leverage his political capital in case of conflict (which I can assure you he did). 

Which brings me to my take away.  The failure of mentorship in my case was not necessarily on the part of the potential mentors in my life. It was a failure on my part to accept mentorship.  A more nuanced view is that I wanted to be in control of the mentorship relationship and like any relationship, it takes two to tango and requires flexibility on both parties to make it work.  My early challenges with criticism led me to a solution that allowed me to learn from others, accept advice, and admit when I am wrong, but not without sorting it out on my own first.  It has certainly not been the most efficient way to get from point A to B in my career but it has allowed me to learn from my mistakes and process advice from various stakeholders into a cohesive plan.  It has also given me the confidence to act but not react.     

For those out there early in their careers and lives, my advice is that in order to have a successful mentoring relationship, you have to be open to accepting the advice and guidance of your mentor.  Which is why I included the second story.  Like any good relationship, mentorship is a give and take.  The person being mentored needs to be open to guidance, criticism, and re-direction while the mentor must be willing to give of their time for the benefit of the relationship and not for their own self interest.  A mentor is not a boss. Following orders does not lead the mentee to independence which is the ultimate goal.  A mentor is also not a parent.  That level of obligation to another individual I believe is reserved to loved ones, close friends, and family.  Instead, like a good teacher, a mentor supports and guides without manipulation or direct gain.  It sounds a lot like finding a soul mate but I would not go that far.  However, it is a commitment that requires openness and investment by both parties. 

No matter what stage we are in, we can all use mentors and can find fulfillment in mentoring others.  That is why I don’t believe my “mentor ship” has sailed and I encourage everyone to seek out others to help them on their life journey. 

If you are looking for a theme to this blog, I have one.  The theme is not simply writing about what happens to be on my mind.  It is true, that I like to write about a variety of topics and my inspiration, like most people who enjoy writing, is based on what I know.  However, the overarching theme is really to write about topics that touch upon our shared humanity.  We have much more in common with each other despite efforts of the world around us that try to emphasize our differences.  I hope that in some way, my various posts will emphasize this point and encourage all of us to see what links us to others around us and throughout the world. 

As I mentioned in my last post, I am a urologist.  For those of you who are unfamiliar with this medical specialty, you may want to stop now and remain blissfully unaware.  I tell my patients, urologists are the plumbers of the medical world.  Unlike a nephrologist who focuses on the filtering function of the kidney, a urologists deals with parts of the genital and urinary tract that have gone bad or are obstructed (blocked) in some way.  It is a broad field that combines medical and surgical care, benign and malignant disease, and spans diagnosis, treatment and surveillance for many conditions. 

I have a heavy emphasis on surgery in my practice.  Like many surgeons, days in the operating room can be both exhilarating, stressful, and tedious all at the same time.  Not to delve into details but most of my practices relates to care of patients with urologic cancers and a major focus of my practice is robotic-assisted and minimally invasive surgery.  Last week, I had a long day planned with three minimally invasive surgeries.  How long a particular surgery takes is dependent on a long list of variables that include patient factors (prior surgery), disease factors (complexity of the problem the patient needs surgery for), and process/system related factors.  For the most part, I know what to expect for the first two variables.  I have been in practice for a while and knowing how a patients’ medical and surgical history will impact my surgery have come through trial and experience.  I also know how long in general it will take me to address a particular surgical problem-  an organ that needs to be removed completely or partially for cancer or other disease.  What I have less control over is the system/process level issues that I will face in any given day. 

Surgery takes a team.  Some surgeons practice in an environment where they have a consistent team that they work with all the time.  That is not true for me in an academic medical center and may not be true in other settings for other surgeons.  With a very fluid operative load at many academic medical centers, those who are managing operations in the OR need the flexibility to assign anesthesia teams, circulating nurses, and scrub techs/surgical assistants based on which surgeons are operating on a given day, how many surgical cases there are, what types of surgeries are running that day, how many hours of standard staffing the surgical team has, and a number of other variables.  This could mean that I start off with one team at the beginning of the day that changes over the course of the day as staff get pulled to other rooms based on their expertise, shift changes, or a number of other reasons.  This is for the most part done in the name of efficiently managing patient care and the needs of the staff, surgeons, and anesthesiologists.  This also doesn’t take into consideration the members of the team that are not directly involved in the surgical care: pre- and post-op nursing, techs that turn over the room, people who clean instruments to name a few.  A wrinkle in a normally scheduled day can occur if any of these people become scarce or unavailable. 

That is why my day last week was close to perfect.  I had a surgical day that started on time and ended two hours earlier than I would normally anticipate based on the uncertainty of staffing and surgical complexity.  The reason for this was not because I operated fast or cut corners.  The primary reason for this great day in the operating room was because I got to work with the same team from start to finish.  What was even better was that I worked with a group of highly skilled people that had experience with the type of surgeries I perform.   

This “perfect day” generated some thoughts and points I hope to discuss here.  My initial reaction was one of gratitude toward all the people I worked with that day.  The mantra amongst many physicians (especially those who tweet, blog, or communicate through social media) is that the practice of medicine is getting worse and many physicians are leaving medicine because of the hurdles placed in front of them to care for patients.  Here was a counterpoint to this argument-  I spent the whole day doing what I was supposed to do thanks to the great team that I got to work with that day.  At the end of that day I thanked my team individually and sent each one a note telling them how they made a difference in caring for patients that day.  In addition, I sent an email to all of their supervises expressing my appreciation but I also emphasized several important points. 

My first point (that is going to sound like a broken record) was that individually, none of us could have accomplished this feat of excellent surgical care and efficiency but putting the right team together allowed us to do this.  I don’t need to go over the data- we all know that putting consistent teams together improves performance. When people work together over time, it allows everyone to learn how each person communicates, their strengths and weaknesses, and most importantly to establish processes.  Throughout the day, the circulating nurse and scrub tech not only made sure the right equipment and supplies were available but also edited my surgical preference card to reflect what we needed to do the surgery accurately. 

Which brings me to my second point.  Doctors fleeing medicine will not solve the challenges that all clinicians face in caring for patients.  I could have stopped at thanking my team but I emailed everyone’s supervisor to emphasize how good our care can be when the system works in an ideal state.  “Defending in place” to steal a critical incident term and trying to improve the system from within has a better chance of solving the problems we face than leaving the system all together.  We are all replaceable and as more physicians leave practice out of frustration, Health Systems will develop alternative strategies.  The risk is that these strategies will not meet the standards of care that we expect for our patients.  If our motivation is to deliver care to people who need it, doctors need to be part of the solution and not merely vocal victims outside the system.  People have developed various mechanisms to fight back- large single specialty groups, concierge care just to name a few but underlying these are financial motivations.  Financial needs of physicians who have expended a huge opportunity cost to become doctors is an important consideration but we must marry this with the obligation of a physician to help our fellow human beings be healthier and alleviate suffering.  I think it is hard for physicians to do this in these alternative models because, by nature, they are adversarial to the established systems.  While these models can be change agents, they need to take into consideration the broader issues of health and wellbeing (beyond financial remuneration) to have a seat at the table for making clinical practice for all clinicians better.

My third point again might seem stale but it is important to call this out in the hierarchical system of medicine and particular surgery.   Surgery, especially high risk surgery, has historically been a cult of personality.  The expert surgeon is both revered and feared.  This has created environments in the past where surgeons who mistreated their team in the OR were given a pass because of what they were able to do.  I find this totally unacceptable as someone who cares about patient care.  Often, surgeons who function in this way wind up working with people who are considered “survivors” because they keep their mouth shut and do what they are told.  While on the surface, this might seem effective, in emergency circumstances or cases where that surgeon is not performing at optimal level, the fear and culture created in that environment prevents the rest of the team from speaking up.  Unfortunately, we see this all too often.  Our surgeons are aging and the medical community continues to grapple with how to value experience of a senior physician but understand the limitations of all of us as we get older.  In addition, age often has nothing to do with it.  If certain people had not spoken up, how long would the neurosurgeon, “Dr. Death” been allowed to maim and kill people who trusted him with their care?  Surgery is a team sport and while the surgeon is often the captain of the team, valuing the experience, expertise, and opinion of all of the members of the team in the OR suite can be the difference between life and death.  I believe that while our education and credentials provide us the skills and expertise to perform certain functions, it does not entitle us to view ourselves as better than someone else.  If you asked an experienced surgeon to act as a scrub or circulator, they would realize quickly that they were not trained to perform these vital roles and everyone in the room must be respected for what they contribute. 

I’m going to make one more point.  This revolves around the tension in any administrative role responsible for staffing balancing expertise and coverage.  Having held administrative roles, I appreciate both sides of the argument.  As I alluded to above, administrators are not intentionally trying to pull valuable people out of the room.  Their primary responsibility is ensuring that there are enough people to get the days work done.  They have to contend with all sorts of issues- staff calling in sick, staff preferences, unexpected emergencies, surgeries that take longer than planned and numerous other tiny variables that pop up during the day.  While systems are in place to proactively manage this, the “best laid plans of mice and men”….often are foiled by the circumstances we would least expect.  The tension for those on the receiving end to emphasize my point above is that we are not simply widgets.  Putting person A or B into a surgical case can result in vastly different outcomes. 

There is a compromise that to some might seem uncomfortable.  Especially in academic institutions, we labor under the belief that we are “All Above Average” to borrow a potentially tarnished term from stories about Lake Wobegon.  But the truth is, the average needs to be set internally and not externally.  When we do this, we end up with the typical bell-shaped curve where, yes, some of us are above average but others are at or below average.  Inherent to the idea of staffing effectively is the concept of avoiding overtime and attempting to create as much consistency in a schedule as possible.  The administrative solution is to move us around like widgets but this hurts the busiest and most efficient surgeons the most.  The surgeons that operate a few times/month should not be treated the same as those who operate 3-4 times/week.  Running an experiment where key surgeons who set a good team culture in the OR, are busy, and provide consistent outcomes to their patients by ensuring a consistent team (within reason) and evaluating the effect through a PDCA cycle with the metric of surgeon/staff satisfaction, cost per unit of service (which would take into consideration efficiency and time), and patient outcomes (length of stay, readmission) and comparing this to standard staffing would give leadership of a health system data to understand how thoughtful teams impact not only the OR but downstream hospital days and patient outcomes. 

I called this post “Close to Perfect” for a reason.  In healthcare and other industries, we try to achieve perfection but it is an endpoint we will never reach.  We can only try being better every day.  We can’t get better if we leave medicine altogether, fail to value our teams, or are unwilling to consider alternative strategies.  I viewed my day in the OR as a lucky circumstance but luck should have nothing to do with this.  I have had other good days in the OR before and since but it creates a huge strain on me when I am working with the less than optimal team.  Next time you are working with your team, don’t forget to thank them, value them for what they contribute, and strive to be a little better together the next day. 

If you made it here, thanks for reading my post and I appreciate any insights and comments you may have. 

It’s strange for me to start my first blog post with the topic of second chances.  However, like many out there, I as a normal person who goes to work and tries to do my best, be there for my family and friends, and try to do a little good along the way, am struggling to make sense of our country’s political discourse that seems to have room only for the extremes.  But before I delve into my thoughts on how second chances intersect with our current national conversation, I want to let you know where I am coming from. 

I am a first generation American.  My parents were born in Israel and immigrated to Canada to pursue a college education.  My parent’s dislike of the cold brought us first to Florida, then to Alabama (briefly) and finally to Texas.  After graduating from High School in San Antonio, TX, I began my educational pursuit first in North Carolina at Duke followed by medical school in Houston, residency training back at Duke, and finally fellowship and a faculty position at the University of Michigan. 

Even though I do not love the cold, I have been very fortunate to have a robust career as an academic urologist in Ann Arbor, MI, have three great kids who constantly make my life interesting, and a wife who is a true partner in a hectic life.  Growing up, I was always drawn to stories of adversity that people overcame or people who were given second chances after causing or experiencing tragedy in their life.  I don’t have a great explanation for this.  My life has been pretty good.  Sure, I come from a very modest background but my family has always been supportive of me and I never experienced a time when I did not have what I needed.  But my parents always emphasized the distinction between want and need driving me to pursue meaning over possessions. 

Perhaps what draws me to the whole “adversity” genre is that it is an integral part of the American mythos.  As a naturalized citizen and child of immigrants, the idea of striving to make a better life here in the United States is the mantra of our parents.  Do well in school.  Pursue a professional degree.  Don’t let laziness stand in the way of working hard to achieve the American Dream.  As such, stories of what seemed like regular people overcoming adversity and tragedy to do something meaningful with their lives served as fuel to support my own trajectory. 

 Like many other kids growing up, I played little league baseball.  I was inspired growing up in Lakeland, FL by watching Tigers spring training.  I had less than a stellar career but I especially loved baseball movies.  Perhaps not the best movie of its time, “The Bad News Bears” fit my mold of a great story where the team overcame the adversities of physical limitations, a drunk and burnt-out coach, and socioeconomic barriers to achieve success.  I’m talking about the 1976 Walter Mathau movie, not the 2005 Billy Bob Thorton remake.   To me this movie represented the transformation that could occur when a group of individuals were able to overcome their weaknesses and work hard together to get better.  What always surprised me most about this movie is that they still lost in the end to the arrogant Yankee (not the typical Hollywood ending) but they overcame their individual challenges and got better as a team.   

While the ability to overcome the odds to achieve success can and does occur, we unfortunately live in a time where many people face such extreme barriers that no amount of hard work or effort can help them get over the threshold to achieve their goals.  Bias, hatred, financial barriers, cultural barriers, lack of role models, inadequate education, and many more than I can list prevent people with great potential from ever achieving great things.  Some people will blame it on laziness or the culture from which a person comes from but I think we can all agree that we live in a society where those with access to resources will exceed those without even if the latter’s potential is greater. 

Which brings me back to second chances.  These barriers to success have crept into all of our lives to the point where none of us can shed the mistakes and missteps of our past.   The news cycle was dominated this past weekend by a photo in a medical school yearbook supposedly depicting Governor (of Virginia) Ralph Northam in “blackface” beside someone dressed in a Klu Klux Klan hood.  I have not seen the picture and I don’t want to.  I will never condone the depictions of racism and hatred that have haunted our country since its inception.  I also lack the facts and expertise to comment on what Governor Northam should do. 

This issue brings up a far bigger societal issue that we need to grapple with.  Most if not all of us regret saying or doing something in our past.  Before the advent of the potential for 24/7 exposure of all aspects of our lives, there were only words or pictures (and film) that could catalogue our prior errors.  Today, we and our children are constantly documenting pictures, videos, and thoughts incessantly on a multitude of platforms available for the world to see (unless you restrict your privacy settings and even then, your data still may be sold).  Youth and/or circumstances often lead us, as humans, to say stupid things or behave in stupid ways.  

That doesn’t mean we should take a “boys will be boys” attitude to improper behavior, actions, or words.  But should someone’s entire life be judged by one or a few actions?  In this day and age, it seems that those on the extreme end of the political spectrum or those with a rigid dogmatic view of the world are doing just that.  But I don’t believe it is up to one person or group to decide whether a persons’ errors are unforgiveable.  The extremes of our society view the actions of others through their biased lenses and for individual or group benefit.  As a consequence, this discourse is robbing our society of people who want and can make the world better for all of us as they are picked off for an indiscretion that one group cannot forgive.  It then becomes a self-fulfilling prophecy where only the extremes can survive the scrutiny of public exposure crowding out us normal people who try to do our best every day. 

We as individuals and as a society need a second chance.   It used to be so easy as a kid.  If someone messed up during a game, they could ask for a do-over and most of the time, the other kids would agree.  Kids know that we all need a do-over, a second chance sometimes.  I believe there are a couple of ways we get that second chance.  First, and foremost, the silent majority needs to speak up and engage in civil discourse.  We must ask our elected officials to attend to the work they were elected to do and not to the news cycle, their re-election, or to the needs of their political party or donors.  Leaders listen and act.  We must ask our elected leaders to listen to their other elected colleagues and act on their principles even if they don’t always align completely with their constituents.  We need to demand that our elected officials act with humility and courage to address the shared problems facing our country.  I felt sadness during the State of the Union and Rebuttal last night.  Words of bipartisanship were window dressing for political theatre. 

Second, vote for people with honesty, integrity, and the willingness to serve the people over party or dogma.  Politicians up for reelection need to be judged by actions (their record) and not words or promises.  Finally, those who want to serve should be allowed to explain their past errors and be given the opportunity to make amends to voters and neighbors and not to ideologues or the partisan news cycle.  I know this sounds naïve and simple but if we could allow a do-over on the playground as kids, we can certainly at least give our fellow human beings an opportunity to explain their past.   

I’ll leave you with a final thought.  I am now on my 4th reading of the Harry Potter series.  First was on my own as a young adult and the three additional times are with each of my children as they get old enough to appreciate it.  Reading to my children is one of the best parts of my day.  For those of you who have read the books and/or seen the movies, a recurring theme is that Dumbledore, the Headmaster of Hogwarts, is known for giving second chances.  Despite everyone’s distrust of Severus Snape, Dumbledore judged Snape on the totality of his actions and not his past.  His past was not forgotten but it was understood.  It always comes as a surprise to me as I get to the end of the series with each of my children when they realize that Snape made the greatest sacrifice and was a true hero even more than Harry Potter.  How many people are we preventing from making our world a better place by not offering them a second chance?

Thanks for joining me!

Good company in a journey makes the way seem shorter. — Izaak Walton