Things That Wear Me Out

In ascending order, here are the work-related things that have worn me out recently:

Sort of tiring, but exhilarating:

Spending the entire day in the operating room.

Sometimes difficult, but not too bad:

Spending two hours making patient-related phone calls.

Truly tiring:

Spending all day in clinic.

Tiring and also painful:

Spending two hours dictating the charts of the day in clinic.

Absolutely exhausting:

Spending all day teaching six periods of high school health class on the dangers of smoking.

I really respect teachers. How do they do it?

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.

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.