The Power of Words

A recent cover of Time Magazine featured an article called "Bitter Pill: Why Medical Bills are Killing Us" by Steven Brill. It is an absolute must-read. The whole article probably took me over an hour to get through, as there are so many great quotes and stories. The title explains everything. Intertwined amongst many depressing anecdotes are a few moments where one can find inspiration. As I launch into writing about the "softer side" of medicine, it is good to know that there still is power in words. Below is a quote from the article that demonstrates how influential physicians can be in the lay press if they push the right buttons.

Bach, the Sloan-Kettering doctor and policy wonk, has become so frustrated with the rising cost of the [prescription] drugs he uses that he and some colleagues recently took matters into their own hands. They reported in an October op-ed in the New York Times that they had decided on their own that they were no longer going to dispense a colorectal-cancer drug called Zaltrap, which cost an average of $11,063 per month for treatment. All the research shows, they wrote, that a drug called Avastin, which costs $5,000 a month, is just as effective. They were taking this stand, they added, because “the typical new cancer drug coming on the market a decade ago cost about $4,500 per month (in 2012 dollars); since 2010, the median price has been around $10,000. Two of the new cancer drugs cost more than $35,000 each per month of treatment. The burden of this cost is borne, increasingly, by patients themselves — and the effects can be devastating. 

The CEO of Sanofi, the company that makes Zaltrap, initially dismissed the article by Bach and his Sloan-Kettering colleagues, saying they had taken the price of the drug out of context because of variations in the required dosage. But four weeks later, Sanofi cut its price in half.

Emphasis added for effect. It can be hard to quantity the amount of change words can make. Change usually cannot be measured (unlike this case!). I recently listened to a speaker here who believes that 95% of medical research is total crap. Either the methodology is poor or the authors published just for the sake of publishing (longer CV, anyone?). The key is to be a part of the 5%. Write or research something that will make a difference. Maybe it will change the way physicians practice evidence-based medicine; maybe it will improve patient outcomes; or maybe it will change the culture of medicine entirely.

I hope to be a part of that change.

If you get a chance, spend some time on this article. Whether you are a patient or a provider, everyone should understand our health care system just a bit better, no matter how messed up it is.

Soup in a Blizzard

A mix of food and medicine today. I recently met some of the upper surgical brass at Brigham and Women's Hospital here in Boston, and I left with a warm feeling. Anytime I have the opportunity to actually get to know attending surgeons who work with the residents at a hospital, I am impressed. I usually leave thinking, "Sure, I can see myself here." Then I go home and add that place to The List.

The thing about The List is, it's a fickle business. Anything can cause me to drop a residency from The List at a moment's notice (and it usually has to do with the weather). Thirty-five straight days of rain in Seattle? University of Washington takes a nosedive. Windchill of -10 degrees in Chicago? Ouch, Northwestern. Twenty-seven inches of snow in Boston? Bye-bye, Brigham.

So I left the Brigham hospital saying, "Boston, ain't that bad." And then I walked outside and got smacked in the face by a 40 mph gust of frigid air. It was 15 degrees Fahrenheit and blustery.

I said, "NOPE!"

To cheer me up, I found this amazing recipe online, since I felt soup was in order. It is a very hearty soup (which is the only kind I like) that will hit the spot on a cold day. I modified some of the ingredients so they are cheaper and easier to find in your run-in-the-mill grocery store. It serves 4-5, and takes about 30-40 minutes to make. Quick and delish. Enjoy!


Ingredients

• 2 tablespoons of olive oil
• 4 ounces sliced mushrooms, ¼-inch thick (2 cups)
• 1 large onion, diced
• 1 teaspoon dried Italian seasoning
• 6.5 cups low-sodium vegetable broth
• 6 ounces pappardelle noodles (I used wide flat egg noodles; see picture above)
• 1.5 cups green beans, cut into 1-inch pieces
• Half cup mascarpone cheese
• ¼ cup fresh Italian parsley (I went with dried parsley and it worked just fine)
• 4-5 cloves garlic, minced
• 1 lemon

Steps

1. Heat oil in pot over medium-high heat. Add mushrooms and onion, and sauté for 5 minutes. Stir in Italian seasoning, then broth. Cover, and bring to a boil. Set aside 1/2 cup broth, then add noodles; simmer for 3 minutes, stirring occasionally. Add green beans, and simmer for another 3 minutes. Remove from heat.

2. Whisk mascarpone into the reserved 1/2 cup hot broth in bowl. Slowly stir mascarpone mixture into soup. The mascarpone is stirred into this noodle soup just before serving to give it a luscious creaminess and cheesy tang.

3. Garnish each bowl with parsley, 1 garlic clove, and a quartered lemon (squeezed). Serve immediately.

Leaders on Top o' Leaders on Top o' Leaders

Let's do a little thought experiment together, shall we? I want you to imagine a world where everyone thinks they are a "leader." Everyone. Not only do they think they are leaders, but they think they are the "best" leaders. The cream of the crop. Perhaps they believe they have been "hand-selected" as the next round of individuals to lead our great nation. Now I want you to imagine putting 100 of them into a room together. This is a class on leadership. And within this class, give them a leadership exercise in which they must analyze their own leadership, as well as the leadership of others. Finally, mix in the fact that grades are assigned, add a little bit of institutional arrogance, and prime the pot by telling the students that in all likelihood, none of them have ever truly been a "leader." Now what happens?

I'll tell you what happens: an all out Lord of the Flies world, aka my Mondays and Wednesdays from 11:40am to 1pm.

I should be getting used to this by now. In my Leadership and Management class last year, we had a similar scenario occur during a clothing drive for the homeless (yes, for the homeless; class competition + #EveryoneWantsToBeALeader = angsty passive-aggressive email strings and more). And my Leadership class this semester is turning into something similar. Neither of these examples, however, can compete with my experience this past weekend during a Hidden Lives of Groups workshop at the Center for Public Leadership. Yes, I am that nerdy; I volunteer for weekend leadership seminars, although this might be my last...

What was discussed within and among groups is confidential out of respect for my peers, but I think I can paint a pretty good picture. You can fill in the details. The event was a day and a half, mainly consisting of three 1-hour "group" sessions, and one longer "intergroup" event. There were five groups, each with about 11 Harvard students in them. Each group session was an hour long, with the only task being to "analyze and understand the behavior of the group in the context of leadership and authority." That's it. Oh, and there was a psychologist sitting with each group to constantly fan the flame. The groups met twice, and then had a two hour event where all the groups could intermingle. Then the individual groups talked again on their own. Sounds like pretty benign exercise, right?

Wrong. Social psychology initially became popular after World War II. People wanted to understand how the Nazis could commit such atrocities. How did they convince good people to do bad things, or were all the Nazis just innately evil? The latter was the prevailing theory for some time, until experiments were conducted that demonstrated how "Lord of the Flies" we really are. Famous experiments showed how willing people were to obey an authority figure's request (even one they just met), to repeatedly inflict electric shocks on another human being (here's the link to the Wiki on Milgram's famous study). In reality, no one was actually being shocked, but the experiment was designed such that the individual being tested thought so. Other well known research studies have shown the divisiveness of simply giving half a third grade class red shirts to wear, and the other half blue shirts. Perceived differences can be very dangerous.

Back to our story. By the end of the weekend, the groups were at each other's throats. You're not doing the exercise right! We are! We have conflict! You are a bunch of babies! Rah rah us!! The language used amongst the groups was gross. Power struggles ensued. Groups allied. Collectively, many believed their group was "better." Thank God I'm not in one of those other groups! But many of us asked, what were we competing for? Why did people feel the need to be in the "best" group? What would they gain in the end? Nothing. Nothing would be gained (except hopefully some new insight to group dynamics). Nobody won power or money; no one got an "A" or extra credit. Nobody's careers were on the line. We all would simply walk away that Saturday night, back into our own lives. Yet there was such an intense need to be the "best," to be powerful, to be a "winner."

I left the exercise defeated and exhausted. On Monday, when I realized that my Leadership class may be similar to the Hidden Lives of Groups in a lot of ways, I was concerned. I've never held a Hobbesian view of our world, but it's hard not to after this much time with intense "leaders." There are some wonderful people here, but I ain't in Kansas anymore. I've always thought I wanted to be a leader, but I left on Saturday wondering why. And I know I wasn't the only one who thought this (in reflection, what does this say about my own leadership?).

Sometimes I ponder: if we are supposed to be the future leaders of this country, America is screwed.

One of Them

It's still as white as it used to be. I must admit, though, this is not a "good" thing. If your "white coat" is still "white," it means you haven't lived in the trenches. You're a newbie, a novice. You haven't been on the wards, you haven't changed a patient's dressing or pulled a drain. A good white coat should have a respectable amount of stains and splotches, and remnants of old spillages of blood and pus (even after being laundered). It can't be obvious though; that would be unacceptable and unprofessional. You shouldn't be able to read the stories those stains could tell unless you look very, very close. But the coat can't exactly be "white." It should be a shade off.

But my white coat is still white. I am proud of that. It's not that I haven't lived in the hospital. To be honest (will you keep my secret?), it's my own little rebellion. Any opportunity I have, I don't wear it. My attending physician isn't wearing hers? Mine gets left at home the next day. About to examine a patient? I hang it up by the door. Beginning rounds? My white coat rests gently on the chair where I finish writing my morning notes.

There are two reasons I detest that thing. The first is pure vanity. It doesn't fit me. All medical students wear the "little" white coats, instead of the long cape-like lab jackets that adorn real doctors. Those are trim and fitted. Mine, though, because of my Inspector Gadget-like arms and slender torso, is ginormous. I had to purchase one that would fit Shaquille O'Neil just so the arms were long enough. And in the front, I could fit three of me. Because of my height, it is especially short. It rides up to my belt. So I don't like it, and I'm too cheap to buy a new one.

The second reason, though, is the real impetus for my mini-revolution. For me, the white coat is the divider: the "Us vs. Them" statement. It is the one thing that a patient cannot have and a physician can. "It's ours! And ours alone!!" The lab coat is what distinguishes the patient from the provider. When I walk into the clinic with a stethoscope around my neck instead of a tie, free of any outside garment, I feel more connected. My attire says, "Hey, I'm still one of you! I'm not one of them yet. You can trust me." And I like that. I'm a human being, not some all-powerful demigod, to whom thou shall not speak. The coat yells, "Heed my words, for they are written in stone." But why? We are all fallible. We are all human. In some ways, we are all patients and all doctors of our own bodies. So why wear the coat?

Truth be told, this thinking is most likely the product of the environment where I grew up. There are no doctors in my family. There are no health care providers either. I met some great docs in my younger years, but I also met some physicians I couldn't stand. Ones with poor bedside manner. Arrogant. Entitled. I actually began medical school with a negative view of physicians (and I've had classmates who reinforced this view). As I've entered this new world, I have seen both: the wonderful, the caring, the human, juxtaposed with the disdainful, the power-hungry, and the money-driven. Now I need to be fair, the white coat doesn't put you in one category or the other. It has just always represented the latter to me. It symbolizes the medical community as an institution, not as its good actors. So every chance I get, I ditch the coat, leaving it out of sight and out of mind. That is why my white coat is still white.

Another admission: there actually are some good reasons to wear one. Pockets. Lots of pockets! So many wonderful pockets. In the left chest pocket I horde pen-lights and patient notes. My Surgical Recall resides in the right pocket near my waist. The left side pocket holds my trauma shears, reflex hammer, and other pointy objects. And the inside pockets hide my secrets... granola bars, tic-tacs, and cheat-sheets. The only problem with these pockets is that they aren't very sturdy. I've had to sew up the outside waist pockets because my pointy tools were cutting through the fabric (I, of course, used silk suture from the OR to sew the pockets back on, in order to practice - unfortunately the suture was black).

The white coat is also a good barrier from bodily fluids and from house staff questions. I was vomited on once, and I was pretty happy to be wearing a protective garment over my nice collared shirt and khakis. Also, when you are wearing a short white coat, the house staff knows you aren't a resident; thus, they don't ask you the important questions about their patients (they already know you don't know the answer). In fact, there have been occasions when I wished it was obvious who I was, just to avoid the awkwardness of my own naïveté...

So it's still pretty much as white as it used to be. But only sort of. The parallel black rows of silk that line the bottoms of each outside pocket are noticeable. It is clear that an amateur has altered the fabric. If you look very closely, you will see a yellowish discoloration on the right from vomit, though it is very faint. From a few feet away, you still can't tell the coat has been worn. Maybe not a lot, but it no longer appears brand new. Something, or someone, hides within its protection.

The more I scrutinize the coat's exterior, the more I realize I am changing. I am slowly, quietly becoming one of "them." A pure white coat means you are still living in the world of the classroom. You don't know the harsh realities of the hospital, of the operating room. You have yet to discover what it feels like to be on the other side of the fence. The coat does not yet define you. A worn white coat means something else. Despite confidence in my ability to win my rebellion against this transition, my white coat is beginning to say otherwise.

Slowly, I am becoming one of them. But I'm not sure what that means.