Learning to Drive

I have helped teach four kids to drive a car. I have trained sixty otolaryngologists to operate. Both are daunting tasks that I have taken seriously.

In learning to drive, the kids were always straining at the bit. They wanted to go a bit faster, a bit more enthusiastically, and a bit more carelessly than I would have prefered. I would turn off the radio, confiscate the cell phones, forbid distractions, and talk about the finer points of driving a car as they drove.

As we moved through the kids, the state laws became more strict about mentored driving, night driving, and not having non-family members as passengers. I agreed with the changes.

The kids, of course, thought I was nuts. They were ready to drive well before I was ready to let them.

"C'mon, Dad! I have been driving for a whole month! Let me take the car!"

I would try to explain my anxiety by drawing on my experience teaching surgery:

When a new resident starts training, he or she spends a lot of time observing. This goes on for many months. He or she begins by performing simple portions of procedures under absolutely strict observation.

As they become competent, the residents are allowed more and more responsibility, still under the watchful eye. Even when they are almost ready to graduate and begin to practice on their own, they are scrutinized, evaluated, and corrected. It is a long process.

My point to the kids was always this:

Driving a car is a lot like learning to be a surgeon. No matter what you might believe, you begin by being completely incompetent; neither driving nor surgery is intuitive. You learn incrementally and develop skills. You find out how to get out of jams and tight spots. You learn to anticipate what might happen and make adjustments. You develop the ability to to plan three or four steps ahead.

The biggest difference? In surgery, the training takes five to seven years and you can only harm one person at a time. Why should driving a car, with so much potential to destroy so many more lives simultaneously, take any less time to learn?

The kids would just shake their heads.

Quilting

Over at “Suture for a Living,” you will often find a quilt, because the author is both a plastic surgeon and a quilter. Today, I have a quilt on my blog, as well.

This is a quilt that includes all of the names of members of White Oak Presbyterian Church, the country church in southwestern Missouri to which my great-grandparents, and later my grandparents, belonged. The quilt is dated November 6, 1897.


Missouri was a border state during the Civil War and a major battle was fought in Carthage, Missouri, about twenty miles from the site of my great-grandfather’s homestead. The memories of the war were still fresh, as evidenced by the flag of the Confederacy in the center of the quilt.

The quilt contains the stitched names of the church members, including my great-grandfather, George, my grandfather, Harold, and his twin brother, Warren. My grandfather would have been nine years old at the time. My grandmother’s family, the Briggles, are also represented since theywere also members of the church.

The church membership dropped after World War II as farming and rural life changed. The congregation is no longer active and the building was recently sold. Running my hand over the carefully-placed hand-stitching reminds me, however, that the quilt remains intact and is as vibrant as the day it was completed.

Disparities

It is impossible for a man to learn what he thinks he already knows.

-Epictetus

Every once in a while, you learn something about yourself you would rather not learn.

I consider myself to be an open, compassionate, and caring physician, not unlike most physicians. Oh, sure, there are times when I don't spend the time necessary for a complete understanding of a patient's problem, and, of course, there are other times when I don't know how to negotiate the barriers between a non-English speaking patient and myself. Still, my training and background equip me perfectly for working with patients from all backgrounds, right?

This week, while at the annual meeting of physicians in my specialty, I attended a session entitled, “Cultural Competency, Health Literacy, and Health Disparities.” The presentations opened my eyes.

There is no secret that people of color, the underinsured, and the disenfranchised in the US have higher rates of cancer, poorer survival, and delays in accessing the health care system. This was reinforced by the data presented.

What shook me was that we physicians are both knowingly and unknowingly complicit in this disparity. One study of California physicians indicated that, given the same indications for tonsillectomy in a child with commercial insurance and one with Medicaid, the physicians would be less likely to offer the procedure to the child with Medicaid. Despite this, a national survey found that we believe that we treat all patients equally, regardless of insurance status. Obviously, these findings are at odds with the other. It is possible that we are lying to ourselves.

A recent study in my specialty demonstrated that the vast majority of surveyed physicians were not familiar with the term, “Health Disparities.” As I listened to the discussion at the meeting, it seemed apparent to me that we need to not only make middle-aged white male physicians (like me) more effective, we must enlarge our ranks with physicians who come from the affected cultures.

Attracting people into a specialty, especially one that is encountered by only a fraction of medical students is a challenge. By being intentional, however, Otolaryngology has become a surgical “specialty of choice” for an increasing percentage of women over the past 20 years. Given the discussion after the presentation, I hope we will strive to make it a specialty of choice for people of color, as well.

Grand Rounds

Grand Rounds 5.1 is hosted by Dr. Val, a recently URL-challenged PM&R physician of many talents. She is a blogger extraordinaire and shoulder-rubber of people in high places. You can find Grand Rounds here.

Uncertainty

Medicine is a science of uncertainty and an art of probability.
-Osler


The cancer had been treated several years before. No recurrences and no new problems. Still, his wife remembers all of the details.

"I was really scared when we learned he had cancer," she reminds me. "It was a terrible time."

I remember, as well. There were many phone calls, anxious appointments, consultations, and questions. And there was one significant delay.

"Remember how long we had to wait for his surgery, Doctor? That was so horrible!"

Yes, I do remember. I had squeezed in his initial appointment on an off-clinic day just before I was going out of town for a much-anticipated family vacation. Before I left town, I had arranged his evaluation and had set everything up. There were plenty of instructions to provide and appointments to confirm. Still, my vacation had ended up delaying his surgery by several days. I could not deny that.

"Oh, Doctor, I was so certain that the cancer would have grown too large for surgery by the time you got back into town! I was certain that he would die!"

I had spent time reassuring her then, and I try to reassure her now. My usual discussion runs along these lines:

"By the time a cancer is big enough to be seen, it has usually been growing for several months. A delay of a few days should not matter." Still, I knew then and know now that tumor growth rates in a laboratory Petri dish might be different than in an individual.

She looks at me again. "Doctor, are you absolutely certain that he will be all right?"

Her question reminds me once again of that wonderful family vacation – and the few days’ delay in her husband’s surgery – that had occurred years ago. Not knowing with absolute certainty, I smile and assure her that he will continue to do just fine.

Grand Rounds

Here is a link to this week's medical blogosphere Grand Rounds at Nurse Ratched's Place. Check it out for the great antique photos and devices. My post is the very last one on the list!

Best for last? or Listed by quality of writing? You decide...

PIN Night

We went to PIN Night at the high school last week to follow our youngest child’s class schedule, meet her teachers, and hear about her upcoming year. (“PIN” stands for “Parent Information Night,” so I guess we went to Parent Information Night Night.) Because our oldest started grade school in 1988, this was our 20^th year of PIN Nights. These events are important venues for understand grading policies, classroom rules, and curriculum objectives; I applaud the school district employees for the time and effort it takes to mount these events each year.

However, as my lifetime of attending these events is drawing to a close, these are the things I will actually remember about PIN Nights:

- When I started attending PIN Nights, most of the other parents looked REALLY old. Now most of them look REALLY young.

- The teachers always looked young. Now a lot of them look even younger.

- At each PIN Night, I realized that many of the classes sound really interesting; This year, I wish I was the one taking Environmental Science, AP Biology, French, or World Literature.

- PIN Nights have reminded me that I remember next to nothing of the math I took in school. I don’t even understand the stuff posted on the walls in the math rooms. The calculators have too many buttons.

- PIN Night shows me how schools have changed – more technology, more expertise among the faculty, more services, truly outstanding music programs, and more awareness of individual differences

- PIN Night also reassures me that a lot hasn’t changed.

As we sat in one of the classrooms last week, I scanned the blackboard looking at all of the reminders, assignments, and information. Most of our kids have had this teacher in this classroom; I once spoke to students in this room about what I do for a living. The room reflects the educator who works within its walls – as I listened to the presentation, I sensed again that students passing through this place experience high expectations and stringent standards. I was able to sense how intimidating that could be for a kid, yet very rewarding.

But, of course, we are done with PIN Nights. Now, we are experiencing college parent orientation events. Unfortunately, college events just aren't quite the same as PIN Nights. Fortunately, the college parents still look REALLY old - at least for the time being.

“Healing the Doctor Patient Divide”

The New York Times Health Blog “Well” edited by Tara Parker-Pope, published an article by Pauline W. Chen, MD this week. Dr. Chen, author of the best selling book, Final Exam: A Surgeon’s Reflections on Mortality, will write a new online column in the Times called “Doctor and Patient.”

The premise of Dr. Chen’s essay is that we “all want the same thing: the best care possible. But we have lost the ability to converse thoughtfully with one another. And because of that loss, we can no longer discuss the meaning of illness, care, health and policy in a way that is relevant to all of us.” She hopes that building an online community will bridge the gap.

If the readers’ initial reactions are any indication, she has struck a nerve. The first 300 comments range from patients ranting about bad personal experiences with physicians focused entirely on wealth accumulation to physicians ranting about a system that has screwed them. This is a target-rich environment: everyone from government to medical schools to HMO’s to insurance companies to lawyers to the economy to primary care reimbursement to societal breakdown is to blame. Solutions are rare.

I’m not certain that this forum will build community, but it makes interesting reading. I look forward to her columns.

Choosing a Specialty

The most difficult thing is the decision to act.
-Amelia Earhart


When I was in medical school, I had to choose a specialty. Because I liked everything and because I worked in a hospital with a Family Medicine residency program and had gotten to know and respect all of the trainees, I was certain that I would go into Family Practice. I was even in the Family Practice Interest Club at my medical school. I was certain of my career path.

Then, I rotated through Obstetrics.

Suddenly, I was not so certain. I did not like delivering babies. When deliveries go well, they are great. But, occasionally, things go very wrong. Besides, babies can come any time of the day or night. They even had a faculty call room on the OB ward in the hospital. Ugh.

So – now I liked everything except OB.

What is Family Medicine minus Obstetrics? Right! Primary Care General Internal Medicine! This looked perfect. Continuity of care, lots of time to meet people (or so it seemed at the time), and no Obstetrics. Ideal.

Then I rotated as a Surgery sub-intern. I realized that this would be my final surgical rotation in school. I would never be in the operating room again! I had loved the OR – its energy and the excitement. Realizing that I would never again be in that environment made me both sad and ripe for suggestion.

A couple of days later, an ENT surgeon asked me what specialty I was pursuing. “Internal Medicine!” I responded proudly. “Do you like diabetes and hypertension?” he asked. “I dunno. I suppose,” I responded hopefully. He just stared at me. “You go into Internal Medicine and you will spend the next 35 years of your life just taking care of those two diagnoses!!!” He turned on his heel and walked away.

Needless to say, this was disconcerting. What if he was right? I paused, trying to figure out exactly why I had ruled out a surgical field in the first place. Then I remembered: At 6'2", I could not find scrub clothes that fit. I was not going to spend the rest of my career wearing scrub pants that were too short!

“I think I can get over that...” I thought to myself.

A few weeks later, I was in an Otolaryngology residency program and I have never looked back. Once in a while, though, I happen to look down, and sadly realize that my scrubs pants are still chronically too short. Maybe no one has noticed.

Bear in Mind…It’s Wednesday

What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others.
-Pericles

I was rummaging through our rag bucket of old shirts, towels, and sheets a while ago. Out came a faded dish towel with a hard working needlework bear and the phrase, "Bear in mind...it's Wednesday." I looked at it for a minute.

I had seen this towel many times before. There used to be an entire set of them, one for each day of the week. The needlework was done by my father’s mother’s brother’s wife (get that? My great-aunt) many years ago. Given the fact that she was in her prime in the 1920’s, the piece of cloth in my hand was lovingly decorated at least 70 years ago.

Now it’s a rag. Should we regard it as a family heirloom? Should we find a way to display it and preserve it?

Perhaps.

Still, I am certain that touching the rag prompts me to stop and remember my Great-Aunt Helen much more frequently than I would if the towel had been lovingly folded and stored in a chest of drawers. Both the rag and our memories of a long-departed relative still have tasks to perform in our home.

Informality

Saying thank you is more than good manners. It is good spirituality.
-Alfred Painter


This is an announcement of sorts. For the past several years, I have persisted in a routine. Here it is:

Wait staff: “Do you guys have any questions about the menu?” (Kids look at me and smirk)
Me: “No. I think we are ready to order.”
Wait staff: “What can I get you guys?” (Smirk.)
We order.
Me: “Can I have some iced tea, please?”
Wait staff: “No problem.” (Kids stifle grins and look at each other.) “Any of the rest of you guys want anything to drink?” (One kid pounds his thigh.)

After a couple more visits from the waiter or waitress, the check arrives.
Kids: “Dad, I counted six ‘no problems’ and five ‘you guys.’”
Me: “I think you’re right.”

You see, I have joked for years that my tip calculation would be adversely affected every time a wait person substituted a “you’re welcome" with a “no problem," and a personal greeting with a “you guys.” To be honest, the offense has never truly affected a tip, but it has been an unrelenting threat, one which the kids have perpetuated and enjoyed.

Nevertheless, as of today, I am retiring the threat. You think that is a good idea? You do? Well, no problem.

Reflections

My blog "Reflections in a Head Mirror" was started in April 2007, and contains stories and reflections that have been generated by my medical practice as a head and neck cancer surgeon. That site is http://www.froedtert.com/reflections. I have enjoyed the blog for many reasons, but primarily since it has been a place for me to collect medical stories and reflect on how they have changed me. Sometimes, however, I have non-medical experiences or work-related events that deserve reflection but might not be appropriate for the "company" web site. Those observations will end up here.