Monday, November 5, 2012

Modern Medicine: Technology Will Advance, But Human Connection Remains

In a recent NY Times article, “Redefining Medicine with Apps and iPads,” Katie Hafner describes a “generational divide” in medicine. On one side sits the younger generation, at ease navigating EMRs and diagnosing disease with the assistance if digital apps. On the other side of this presumed generational divide, she describes the older generation, worried “that the human connections that lie at the core of medical practice are at risk of being lost.” This juxtaposition begs the question; does the use of digital medicine preclude human connection?

As a recent medical school graduate who has enthusiastically embraced technology, I have no fears that my use of digital technologies handicaps me from sharing the human connection essential for a healing and therapeutic patient-physician relationship.

In medical school, I witnessed much fanfare surrounding the teaching and “importance” of the physical exam. Still I found myself somewhat suspicious of what I was being taught—would it really warrant a workup if a healthy patient displayed “diminished reflexes”? Would I really be able to elicit an abdominal fluid wave in an obese patient, and even if I did, wouldn’t the patient have more urgent symptoms and treatment dictated by more accurate diagnostic testing?

A few times I ventured to express my skepticism, and across the board, my instructors responded as if questioning any aspect of the traditional physical exam was an act of blasphemy. They all assured me it was “very important” and often had an obscure anecdote to illustrate this importance to me.

I tried so hard to believe them. Yet, once I hit the wards in third year, the clinicians’ actions spoke louder than words. Early on I took time to report the minor changes in the patients’ daily physical exams. With great care, I documented new murmurs and the onset of crackles. But quickly I realized that no one cared. If the patient did not have corresponding symptoms, these details were brushed off as a waste of time.

Still I tried to maintain my enthusiasm for the physical exam by doing mini presentations based on material from JAMA’s “Rational Clinical Examination” articles. During these presentations I sensed the attendings reminiscing and the residents appreciating the refreshers. Still, the information I presented seemed little more than a nostalgic intellectual exercise. When it came to patient care, I couldn’t help but notice how rarely we changed our treatment plans based on the clinical exam.

As I look forward to residency, I worry about the limited time I will have to spend with each patient. Knowing the time constraints, I do not want to waste time percussing my patient’s heart when an X-ray or echocardiogram is more efficient and accurate. Does this mean that I do not value human connection? Of course not. Fortunately, I do not need the excuse of an obsolete physical exam maneuver to touch my patient. In forgoing the unnecessary exam, I will have time to take the patient’s hand in my own and ask her what scares the most or how we can make him more comfortable.

Please be assured I am not suggesting the physical exam is obsolete. The physical exam was and always will be an indispensable tool to diagnose and treat patients. Indeed it is imperative we continue to teach and maintain these essential skills. Acknowledging the technological advances in medicine and teaching a strategically streamlined exam would allow educators more time to emphasize the human connection and teach students skills to better connect and relate to their patients.

In his article, A Touch of Sense, Dr. Abraham Verghese extols the importance of the physical exam as a means to convey the message, “I will always, always be there, I will see you through this, I will never abandon you, I will be with you through the end.” Call me crazy, but I hope to take the time saved by my digital technologies and gently place my hand on the patient’s shoulder, look them squarely in the eye, and share the same message in my own words. Technology will never replace this privilege of human connection.

Friday, September 14, 2012

Twitter 101 for Surgeons: How to set up a professional Twitter account

This article was first written in 2012. Surprisingly most of the advice still applies. I edited it slightly in Nov. 2017.

Since starting my own personal Twitter account nearly a year ago, I have mentored numerous peers and faculty on how to get started. I’ve noticed that most surgeons have similar questions and concerns. Below I have detailed the most common questions along with my answers.

Twitter? Isn’t that just a bunch of people talking about what they ate for breakfast? Think again. Twitter is about who you follow. Sure, you can choose to follow celebrities and people who tweet pictures of the donuts they eat for breakfast, but the beauty of Twitter is that you don’t have to. Think of Twitter as millions of people talking at once, and by choosing who you follow, you choose who you want to “listen” to. As an aspiring surgeon, I choose to follow surgical societies, surgical journals, and leading surgeons--literally from all over the world. Through Twitter, I learn about upcoming events, the latest research, and the opinions of surgeons I look up to. I also follow influential non-surgeon physicians and patients who are effecting positive change in medicine. None of the “tweeps” I follow mention what they eat for breakfast. (Well, most of the time anyway.)

But I’m not even on Facebook! Don’t be fooled by the misguided logic that if you didn’t take to Facebook, you’re not going to like Twitter. Twitter actually has a very different flavor and utility. Rather than a purely social network (like Facebook), think of Twitter as more of a “subject” network, where users share information and access it based on common interest. You can take advantage of this endless wealth of information, whether or not you are “friends” with those you are following.

Does Twitter substitute for real, live, face-to-face interaction? No, however it often leads to it. On multiple occasions I have met surgeons and medical students via Twitter whom I then chose to meet in person. Not only did Twitter provide me with these professional connections I would not have otherwise had, it also gave us a common ground to start from, enabling a solid introduction before even meeting. This allowed us to hit the ground running.

Do I really have to join Twitter to stay “on top” of the field of surgery? Of course not, but you may be missing out on a powerful way to connect with your colleagues and learn from others both inside and outside of medicine. (Update: In 2017, my answer is "Yes, yes you do.")

That sounds nice, but I’m afraid I don’t have the time. I’m not going to tell you that Twitter doesn’t take time. As a surgeon, you know that most endeavors that are worthwhile do have a learning curve and do take time. However you do not have to become a Twitter expert overnight. Tread slowly but confidently. I will lay out some basic steps to get you started.

1.   Open a Twitter account at All you need is an email address.

2.   Set up your profile. For your Twitter handle (that “@thing”), I recommend choosing something as close to your real name as possible. Try @FirstLastMD or @DrFirstLast or any variation thereof.

Do I have to log in everyday? Definitely not. Twitter is not something that you have to “keep up” with. You do not need to read every tweet. I repeat: You do not need to read every tweet. It’s like the news. It’s interesting when you feel like tuning into it, but it’s fine if you don’t as well. I like to log into Twitter with a cup of tea. Others might sneak a peek at their Twitter feed while waiting between cases or in line at the grocery store.

I’m not sure I want to use my real name, isn’t it better to be anonymous? No. The days of maintaining an anonymous internet presence are over. Besides, you will only be posting professional tweets, and it’s important you get proper credit for your effort and contributions. Think of it this way--would you attend a conference and introduce yourself as someone else? Would you tell them a fake name just in case you said something silly and didn’t want anyone to remember you? Of course not. Consider your Twitter account an extension of your professional persona. You want it to represent you in a meaningful, memorable way.

3.   Use a real photo of yourself for your avatar (profile pic).

Can’t I use an image of a scalpel or a picture of my kids or dog? Going back to the conference analogy, picture yourself at a conference with a bag or mask over your head--kind of creepy right? You probably wouldn’t expect people to trust you or take you seriously. The same goes for Twitter. Post a real picture of yourself.

4.   Write your Twitter profile bio, in 160 characters or fewer.

My whole bio in 160 characters? Don’t stress too much about this. The important thing is to put something. You can always edit it later. For ideas, I suggest looking at the bios of other surgeons on Twitter. With the character limit, it will be slightly informal. Add your clinical interests and feel free to include something slightly personal to add character, such as you enjoy cooking or play a mean game of tennis. The goal is professional but personable.

You are now ready to confidently enter the Twitterverse. (Yes, there is a “Twitterese” version of nearly every word in the English language...)

5.   Choose some accounts to follow.

How do I choose who to follow? I recommend following liberally, as it only takes one click to unfollow someone if you do not enjoy their tweets.

For starters, I recommend following your professional surgical organizations such as American College of Surgeons: @AmCollSurgeons; the Association of Women Surgeons: @WomenSurgeons; the Association of Academic Surgery: @AcademicSurgery and others. You can search hashtags within your specialty such as #colorectalsurgery, #plasticsurgery, or #ENTsurgery. Following user within your field will give you a solid start. Also be sure to follow conference hashtags and follow those who live tweet. Finally take advantage of Twitter suggestion on who to follow.

What happens when I follow someone? Do they know I’m following them? When you follow someone, they receive an email notice and have the option to click on your profile and decide whether they want to follow you back. Thus you want to maintain a professional image from the first day you sign up for Twitter.

If I receive an email that someone is following me, is it polite to follow them back? You are never obligated to follow someone back. This is the beauty of Twitter. You choose who you read and learn from. When you receive an email notice that someone is following you, I recommend clicking on their profile link. Often, you can determine whether or not you want to follow them from reading their profile. If you really want to be thorough, you can also look at their Tweets and see if their tweet content is of interest to you.

Ok. I have a profile, and I’m following a few people--now what? I recommend laying low for a bit. Spend some time skimming your Twitter feed and reading the links that look interesting. There are many unwritten rules to Twitter and it takes some time to understand how it works and how people interact.

I’m nervous about tweeting. Don’t stress about your first tweet. It’s like making an incision--hesitation suggests lack of confidence and clarity. Jump into the conversation. For your first tweet, you can try something like, "Excited to enter the Twitterverse! Eager to learn and share with fellow surgeons and beyond.” This makes it clear that you are joining Twitter to learn and be part of the conversation. This will make other Twitter users more interested in following you.

What if I don’t have anything to say? Don’t worry about having something novel or witty to say. One of the strengths of Twitter is that it fosters sharing of ideas and information. If you are reading an interesting online article and you see the option to tweet it, go for it! If you found it interesting, it’s likely that your followers will as well. Also, for many people, the majority of their tweets early on consist of “retweets.” If you like something someone else shared, retweet it!

Ok. This gives me a basic start, but I know I’m going to have lots of questions. You’re absolutely right. I recommend that everyone find a designated “twentor.” Yes, that’s a twitter mentor. This will likely be someone younger than you, though not necessarily. Find someone you feel comfortable checking in with from time-to-time with your Twitter questions. Ideally, this person will also follow your tweets and can even give you feedback via direct messages (private tweets).

What about those #hashtag things? See here for an article detailing the use of hashtags in academic surgery.

I hope you explore the rich commentary, conversation, and knowledge shared in your Twitter feed. Don’t be afraid to click on the profiles of those who look interesting. You never know who you will meet!

Thursday, July 5, 2012

The Gift of Time

A little over one month ago, I graduated from medical school. Losing the title of “student” for the first time in my life prompted me to reflect on what I’ll miss most about being a medical student.

Without a moment’s hesitation, I know unequivocally the answer is time. From the first day of my clinical rotations, it was clear to me that more than anyone else on the team, as the medical student I had time. And time has the power to heal.

I took advantage of this gift every opportunity I could. The resultant conversations often impacted the patient’s trajectory. For example in talking with an overweight patient who needed a lung transplant, I learned he had recently lost over 80 lbs in six months. Prior to this realization, the team had feared he was unable to lose enough weight to qualify for a lung transplant. In a one on one conversation with a gang member who was demanding his own room upon transfer out of the ICU I learned he had been molested by a man as a child and was fearful his PTSD would worsen sharing a room with another man. We arranged for a private room.

There were also heart touching moments. Watching the eyes of an 80 year old woman with dementia light up as she sang every verse of her favorite Sunday school song with the palliative medicine team. Or watching a previously paralyzed man surprise his wife by standing up to greet her after his successful spine surgery. I can only hope these moments were as healing for the patients as they were educational and inspiring for me.

It saddens me to know that as a resident, I will no longer have the unstructured time I had as a medical student. I find solace in knowing med school memories of patients will forever be close to my heart. In residency I will strive to be efficient with my duties so when a patient remembers “one more question” as I walk to the door, I will have time to truly listen. Time may not heal all wounds, but it’s in these unscripted moments with patients that I find my inspiration.

Addendum: After writing this post, I came across a great blog post by Dr. Robert Centor titled, "Why do we expect productivity from physicians" arguing that we must continue to value time in the physician-patient relationship. I couldn't agree more.

Thursday, March 29, 2012

Survivor as Physician

8/17/2017: Sharing this again. Inspired by all the courageous women and men of the #MeToo movement. 

8/2/2015: In light of the recent New York Magazine article in which 35 women share their stories of being assaulted by Bill Cosby and the #TheEmptyChair hashtag that followed, I am retweeting my own story in honor of the female surgeons and physicians who have privately shared their story with me and sit daily in #TheEmptyChair.

Yesterday I had the tremendous honor of receiving the UCSF Chancellor's Award for the Advancement of Women. As difficult as it is, I would like to share with you my acceptance speech. I have thought long and hard about "coming out" as a physician and in the end I have decided that if I can share the message of hope and healing with just one survivor, it will be worth it.

As a rape survivor and domestic violence advocate, I have shared my story with dozens of audiences. The majority of those times, I have relayed the lessons of my experience with minimal emotional investment or consequence. However last night, when I sat down to write this speech, I realized that this time is different. In less than two months I will be a doctor. Since getting my acceptance letter from UCSF, in the back of my mind I have always wondered how I would someday reconcile my new physician self with "Heather the survivor." Being chosen for this award has given me the courage to accept that "Heather the physician" will forever be inseparable from "Heather the survivor."

Preparing for this day, I debated how much I wanted to talk about my own story. Then I remembered how lost I felt picking up the pieces after the assault, how I yearned for the stories of other survivors. I wanted to know that recovery was possible.  I wanted to know how I could possibly heal from an invisible wound so deep the only way I could describe it was so say that “my soul was bleeding.”

15 years later, I can tell you that the healing never would have been possible without the commitment and support I received from the faculty and administration at my alma mater, the University of Wisconsin, Madison. From start to finish, my undergraduate degree took 8 years. Whether it was counseling support, excused late assignments, or weekly meetings with the dean and special test accommodations when my PTSD-induced exaggerated startle made it difficult to take my exams in a crowded room, the University of Wisconsin gave me the time and space I needed to heal and the support I needed graduate.

When it came time to choose which medical schools to apply to, I knew I would need a school that could provide me that same kind of support. Against the better wishes of all but my closest friends, I only applied to only one medical school. I literally decided upon UCSF based upon the impression I felt from their website. I did make a few campus visits to confirm my intuition and I made a special UCSF binder with paraphernalia of evidence as to why I felt at home at UCSF. I’d like to share with you two pieces of outreach materials I collected. One is a Sexual and Relationship Violence Resource Guide and the other is a guide for how managers can support faculty and staff dealing with the challenges of domestic violence. It was essential to be to be at an institution that had mechanisms in place for supporting survivors of me sexual and domestic violence. And I knew I had found that in UCSF.

After getting accepted, I looked up the UCSF’s resources for women and printed off the “Focus on Women” website. I took pride in joining an institution that visibly supported women.  I am even prouder today, knowing I will graduate from an institution with a female chancellor, Dr. Susan Desmond-Hellmann. Another document I printed off was Dr. Barbara Gerbert’s “Slow Steps to Change” report on the History of the Chancellor’s Advisory Committee on the Status of Women. I met Dr. Gerbert early on in my time at UCSF and Dr. Gerbert has been a tireless cheerleader and supporter throughout my medical education. Dr. Gerbert chaired the committee that proposed this award to Chancellor Martin in 1994. We wouldn’t be here today without her vision and hard work to make this award a reality.

If I can leave you with one message, it is that we need to provide increased support for survivors of sexual violence and foster a dialogue of healing. According to the National Intimate Partner and Sexual Violence Survey, conducted by the CDC in 2010 and was based on telephone interviews with more than 16,500 adults, more than one in three women have experienced sexual assault, physical violence or stalking by an intimate partner during their lifetime and the same is true for more than one in four men.

When I first began to deal with the emotional and physical health consequences of sexual violence in my life, I found some comfort in statistics such as these. Yet at the same time, I felt a deep sense of confusion—if intimate partner violence were so prevalent why didn’t my doctors know how to address my emotional pain? Why wasn’t anyone talking about healing? I couldn’t help but wonder if I were the only survivor who wasn’t able to quickly get over it and move on with her life.

As I became a vocal advocate, I learned most women and men suffer in silence. If you are a medical practitioner, I urge you to ask your patients about past and current sexual and domestic violence. Just acknowledging that intimate partner violence has an impact on our health can make a big difference. If you are a survivor yourself, I encourage you to share your story with others when it feels safe. My first month of medical school when I began to question if I had what it takes, a faculty member shared her own story of how being assaulted had impacted her medical education many years later. I held her story close to my heart and knew that I would be okay. Creating conversations of healing will allow survivors to know they are not alone and that healing and recovery are possible.

Thank you for this honor and thank you for your support.

Wednesday, February 22, 2012

Mentoring My Mentors: An unexpected opportunity in Twitter

Last year, when I needed a research project on short notice, my mentor, @BarbaraGerbert, suggested I do a “Twitter study” with her.  Dr. Gerbert had recently published PublicHealth Surveillance of Dental Pain via Twitter and she was certain I could find something of interest to research through Tweets. Only in hindsight can I fully appreciate how her suggestion would change my life and the endless opportunities and connections that awaited me in the vast “Twitterverse.” One of my favorite unexpected joys of Twitter has been the unique opportunity to "mentor my mentors."

While doing my lit review on Twitter, I stumbled upon @KentBottles' article, Twitter: An Essential Tool for Every Physician Leader and I started to wonder if perhaps Twitter had more to offer than just research data. As an experiment, I opened a Twitter account. It didn't take long to realize that Twitter was life changing. After discovering the far reaching opportunities at the intersection of social media and medicine, I wanted to share its virtues with everyone I knew. Thus when I emailed my general surgery mentor to see if he would have time to meet during the @AmCollSurgeons' Clinical Congress in San Francisco, I asked if he would be interested in "Twitter 101" tutorial. He graciously agreed.

Also at this conference, I planned to meet my first "Tweet friend", @AndrewMIbrahim who had invited me (via Twitter) to join his new national student group, As fate had it, both my mentor and Andrew texted me at the last minute to meet at exactly the same time. Even though I had never met Andrew in person, I figured it would work out fine--what a better assistant could I have to give a Twitter tutorial with than a fellow med student I met on Twitter? While we did not create an immediate social media convert out of my mentor, Andrew and I were able to convince him that Twitter was more than a passing fad and that its opportunities and applications in academic medicine were vast. Since that time, I have mentored many of my mentors in social media. I have introduced the Association of Women Surgeons to social media by starting and tweeting for their Twitter account @WomenSurgeons.

Ever since my first cup of “inspiration tea” shared with my biology professor during my undergraduate studies at the University of Wisconsin Madison, I have been hooked on the enthusiasm, support, and encouragement I receive from career mentors.  Through every step (and misstep) of my educational journey, my mentors have have been an invaluable source of inspiration and guidance. It has been a great privilege and honor to have the opportunity to "give back" to my mentors through teaching them how to Twitter. I am humbled by their commitment to lifelong learning.

I would like to give a special thank you to Dr. Vineet Arora @FutureDocs for her article, Twitter to Tenure: 7 ways social media advances my career, which has been a particularly useful tool in convincing my mentors that Twitter can benefit both their career and their patients. I would also like to thank the @MedEdChat community for teaching me the power and potential of social media to improve medical education.

Addendum: Since posting this I came across an excellent article on younger doctors mentoring older colleagues.