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A case for building our leadership skills
Let me ask you a question: When was the last time you used the Krebs cycle in the hospital?
Now another question: When did you last have to persuade your boss to give you additional resources?
My guess is that your need for additional resources comes up more frequently than the Krebs cycle. It’s interesting that we spent so much time in our training focused on biochemical pathways and next to nothing on leadership skills, such as ways to motivate our health care teams or the most effective way to provide feedback – skills that we use on a regular basis. Yet, these skills are just as critical as understanding the science behind our daily work.
In the past, I would present my case in the following way:
1. Highlight the importance of the ask.
2. Leverage data to prove the point.
3. Illustrate large-scale implications of the ask.
4. Make the ask.
I’ll use a project to increase DVT prophylaxis rates to illustrate this point:
1. Highlight the importance of DVT prophylaxis: I would focus on statistics that would surprise the audience, such as “Hospital acquired venous thromboembolism leads to significant morbidity and mortality, including more than 100,000 deaths.”1
2. Leverage data to prove the point: “Worldwide, only 40%-60% of patients who require DVT prophylaxis actually receive it in the hospital.2 Our performance leaves tremendous room for improvement – we’re currently at 68%.”
3. Illustrate large-scale implications of the ask: “If we do this, it enhances our reputation as a group, and it will improve hospital revenues.”
4. Make the ask: “I have an evidence-based protocol that we need to implement to achieve results.”
Through leadership courses over the past couple of years, I’ve changed my approach significantly. By leveraging concepts from behavioral economics, we can significantly improve the effect of our work. Here’s how I would conduct that same meeting:
1. Connect with the audience in a genuine way: Start off with “You are quality-minded providers who have taken on major challenges in the past and successfully delivered results, like the time you reduced the rates of catheter associated urinary tract infections.”
2. Make the ask: “I’m here to talk to you about improving our DVT prophylaxis rates. Here’s the protocol we need to implement.”
3. Leverage data to prove the point: “DVT prophylaxis rates at the hospital across town (or at another unit in the hospital) are at 82%. What do you think our numbers are? We’re actually at 68%!”
4. Illustrate large-scale implications of the ask: “We all know this. Patients under our care will die or be seriously harmed if we don’t improve our practice. The hospital will also lose money, which will ultimately impact us. So, we have two options: a) We can continue what we’ve been doing – work as hard as we can and our practice will not improve. b) Or we can decide today to pilot this new protocol and change our practice and performance.”
Let’s look at the changes above in greater detail:
Connect with the audience in a genuine way: Instead of highlighting the importance of the ask with statistics, use an attention getter to connect with the group. Highlighting the fact that the group is “quality-minded” and has surmounted challenging obstacles in the past reinforces the providers’ sense of identity.3 This helps the group think more openly about the proposal.
Make the ask: Now that you’ve captured their attention, make your ask, clearly and concisely, upfront. Remember, in today’s health care settings, we have short attention spans. You’re minutes away from someone getting paged away from the meeting or people checking their emails or the latest Facebook post. Don’t schedule the protocol review as the last item on the agenda.
Leverage data to prove your point: Data are powerful, but only if presented in the right way. Use questions to keep your audience engaged (“What do you think our numbers are?”), particularly around data, where most people decide to switch their attention to their smartphones. Based on your access to data sources, find another unit or institution with a higher performance than yours. State that upfront. It anchors,the group to a higher number, so, when you reveal your current performance, the gap is highlighted. 3,4 In the first case, when the lower national average of 40-60% is presented initially, the group will be happy that their performance is in fact better at 68%.
Illustrate large-scale implications of the ask: There are two concepts at work here: First, loss aversion.3,4 We tend to experience greater psychological burden with losses versus gains. Changing the framing from the fact that the hospital will lose money, versus making money in the first case, changes how we perceive the information. Second, active choice.3 Emphasizing that a decision has to be made today and giving the group a choice around it increases the likelihood of walking out of the meeting with a decision.
With some simple, yet thoughtful, modifications, the message takes on a more effective tone, and, based on my experience, it is significantly more impactful.
So, while I’m a fan of biochemical pathways that enable us to generate energy, I also hope we can integrate leadership lessons into our day-to-day learning and life.
Dr. Afsar is an assistant clinical professor in the departments of medicine and neurosurgery and the associate chief medical officer at UCLA Hospitals.
References
1. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Office of the Surgeon General (US); National Heart, Lung, and Blood Institute (US). Office of the Surgeon General (US). 2008.
2. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet. 2008;371(9610):387-94.
3. Soman D. The Last Mile. 2015.
4. Thaler RH, Sunstein CR. Nudge. 2009.
Let me ask you a question: When was the last time you used the Krebs cycle in the hospital?
Now another question: When did you last have to persuade your boss to give you additional resources?
My guess is that your need for additional resources comes up more frequently than the Krebs cycle. It’s interesting that we spent so much time in our training focused on biochemical pathways and next to nothing on leadership skills, such as ways to motivate our health care teams or the most effective way to provide feedback – skills that we use on a regular basis. Yet, these skills are just as critical as understanding the science behind our daily work.
In the past, I would present my case in the following way:
1. Highlight the importance of the ask.
2. Leverage data to prove the point.
3. Illustrate large-scale implications of the ask.
4. Make the ask.
I’ll use a project to increase DVT prophylaxis rates to illustrate this point:
1. Highlight the importance of DVT prophylaxis: I would focus on statistics that would surprise the audience, such as “Hospital acquired venous thromboembolism leads to significant morbidity and mortality, including more than 100,000 deaths.”1
2. Leverage data to prove the point: “Worldwide, only 40%-60% of patients who require DVT prophylaxis actually receive it in the hospital.2 Our performance leaves tremendous room for improvement – we’re currently at 68%.”
3. Illustrate large-scale implications of the ask: “If we do this, it enhances our reputation as a group, and it will improve hospital revenues.”
4. Make the ask: “I have an evidence-based protocol that we need to implement to achieve results.”
Through leadership courses over the past couple of years, I’ve changed my approach significantly. By leveraging concepts from behavioral economics, we can significantly improve the effect of our work. Here’s how I would conduct that same meeting:
1. Connect with the audience in a genuine way: Start off with “You are quality-minded providers who have taken on major challenges in the past and successfully delivered results, like the time you reduced the rates of catheter associated urinary tract infections.”
2. Make the ask: “I’m here to talk to you about improving our DVT prophylaxis rates. Here’s the protocol we need to implement.”
3. Leverage data to prove the point: “DVT prophylaxis rates at the hospital across town (or at another unit in the hospital) are at 82%. What do you think our numbers are? We’re actually at 68%!”
4. Illustrate large-scale implications of the ask: “We all know this. Patients under our care will die or be seriously harmed if we don’t improve our practice. The hospital will also lose money, which will ultimately impact us. So, we have two options: a) We can continue what we’ve been doing – work as hard as we can and our practice will not improve. b) Or we can decide today to pilot this new protocol and change our practice and performance.”
Let’s look at the changes above in greater detail:
Connect with the audience in a genuine way: Instead of highlighting the importance of the ask with statistics, use an attention getter to connect with the group. Highlighting the fact that the group is “quality-minded” and has surmounted challenging obstacles in the past reinforces the providers’ sense of identity.3 This helps the group think more openly about the proposal.
Make the ask: Now that you’ve captured their attention, make your ask, clearly and concisely, upfront. Remember, in today’s health care settings, we have short attention spans. You’re minutes away from someone getting paged away from the meeting or people checking their emails or the latest Facebook post. Don’t schedule the protocol review as the last item on the agenda.
Leverage data to prove your point: Data are powerful, but only if presented in the right way. Use questions to keep your audience engaged (“What do you think our numbers are?”), particularly around data, where most people decide to switch their attention to their smartphones. Based on your access to data sources, find another unit or institution with a higher performance than yours. State that upfront. It anchors,the group to a higher number, so, when you reveal your current performance, the gap is highlighted. 3,4 In the first case, when the lower national average of 40-60% is presented initially, the group will be happy that their performance is in fact better at 68%.
Illustrate large-scale implications of the ask: There are two concepts at work here: First, loss aversion.3,4 We tend to experience greater psychological burden with losses versus gains. Changing the framing from the fact that the hospital will lose money, versus making money in the first case, changes how we perceive the information. Second, active choice.3 Emphasizing that a decision has to be made today and giving the group a choice around it increases the likelihood of walking out of the meeting with a decision.
With some simple, yet thoughtful, modifications, the message takes on a more effective tone, and, based on my experience, it is significantly more impactful.
So, while I’m a fan of biochemical pathways that enable us to generate energy, I also hope we can integrate leadership lessons into our day-to-day learning and life.
Dr. Afsar is an assistant clinical professor in the departments of medicine and neurosurgery and the associate chief medical officer at UCLA Hospitals.
References
1. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Office of the Surgeon General (US); National Heart, Lung, and Blood Institute (US). Office of the Surgeon General (US). 2008.
2. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet. 2008;371(9610):387-94.
3. Soman D. The Last Mile. 2015.
4. Thaler RH, Sunstein CR. Nudge. 2009.
Let me ask you a question: When was the last time you used the Krebs cycle in the hospital?
Now another question: When did you last have to persuade your boss to give you additional resources?
My guess is that your need for additional resources comes up more frequently than the Krebs cycle. It’s interesting that we spent so much time in our training focused on biochemical pathways and next to nothing on leadership skills, such as ways to motivate our health care teams or the most effective way to provide feedback – skills that we use on a regular basis. Yet, these skills are just as critical as understanding the science behind our daily work.
In the past, I would present my case in the following way:
1. Highlight the importance of the ask.
2. Leverage data to prove the point.
3. Illustrate large-scale implications of the ask.
4. Make the ask.
I’ll use a project to increase DVT prophylaxis rates to illustrate this point:
1. Highlight the importance of DVT prophylaxis: I would focus on statistics that would surprise the audience, such as “Hospital acquired venous thromboembolism leads to significant morbidity and mortality, including more than 100,000 deaths.”1
2. Leverage data to prove the point: “Worldwide, only 40%-60% of patients who require DVT prophylaxis actually receive it in the hospital.2 Our performance leaves tremendous room for improvement – we’re currently at 68%.”
3. Illustrate large-scale implications of the ask: “If we do this, it enhances our reputation as a group, and it will improve hospital revenues.”
4. Make the ask: “I have an evidence-based protocol that we need to implement to achieve results.”
Through leadership courses over the past couple of years, I’ve changed my approach significantly. By leveraging concepts from behavioral economics, we can significantly improve the effect of our work. Here’s how I would conduct that same meeting:
1. Connect with the audience in a genuine way: Start off with “You are quality-minded providers who have taken on major challenges in the past and successfully delivered results, like the time you reduced the rates of catheter associated urinary tract infections.”
2. Make the ask: “I’m here to talk to you about improving our DVT prophylaxis rates. Here’s the protocol we need to implement.”
3. Leverage data to prove the point: “DVT prophylaxis rates at the hospital across town (or at another unit in the hospital) are at 82%. What do you think our numbers are? We’re actually at 68%!”
4. Illustrate large-scale implications of the ask: “We all know this. Patients under our care will die or be seriously harmed if we don’t improve our practice. The hospital will also lose money, which will ultimately impact us. So, we have two options: a) We can continue what we’ve been doing – work as hard as we can and our practice will not improve. b) Or we can decide today to pilot this new protocol and change our practice and performance.”
Let’s look at the changes above in greater detail:
Connect with the audience in a genuine way: Instead of highlighting the importance of the ask with statistics, use an attention getter to connect with the group. Highlighting the fact that the group is “quality-minded” and has surmounted challenging obstacles in the past reinforces the providers’ sense of identity.3 This helps the group think more openly about the proposal.
Make the ask: Now that you’ve captured their attention, make your ask, clearly and concisely, upfront. Remember, in today’s health care settings, we have short attention spans. You’re minutes away from someone getting paged away from the meeting or people checking their emails or the latest Facebook post. Don’t schedule the protocol review as the last item on the agenda.
Leverage data to prove your point: Data are powerful, but only if presented in the right way. Use questions to keep your audience engaged (“What do you think our numbers are?”), particularly around data, where most people decide to switch their attention to their smartphones. Based on your access to data sources, find another unit or institution with a higher performance than yours. State that upfront. It anchors,the group to a higher number, so, when you reveal your current performance, the gap is highlighted. 3,4 In the first case, when the lower national average of 40-60% is presented initially, the group will be happy that their performance is in fact better at 68%.
Illustrate large-scale implications of the ask: There are two concepts at work here: First, loss aversion.3,4 We tend to experience greater psychological burden with losses versus gains. Changing the framing from the fact that the hospital will lose money, versus making money in the first case, changes how we perceive the information. Second, active choice.3 Emphasizing that a decision has to be made today and giving the group a choice around it increases the likelihood of walking out of the meeting with a decision.
With some simple, yet thoughtful, modifications, the message takes on a more effective tone, and, based on my experience, it is significantly more impactful.
So, while I’m a fan of biochemical pathways that enable us to generate energy, I also hope we can integrate leadership lessons into our day-to-day learning and life.
Dr. Afsar is an assistant clinical professor in the departments of medicine and neurosurgery and the associate chief medical officer at UCLA Hospitals.
References
1. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. Office of the Surgeon General (US); National Heart, Lung, and Blood Institute (US). Office of the Surgeon General (US). 2008.
2. Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional study. Lancet. 2008;371(9610):387-94.
3. Soman D. The Last Mile. 2015.
4. Thaler RH, Sunstein CR. Nudge. 2009.
Physician Learns Lessons About Patient Care from Failure
“Are you comfortable talking to him about all this stuff?” my attending asked me casually.
“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.
STOP!
Hold on. What did I just agree to do?
More than a decade later, I still feel the nervous tension in my stomach as I think about that day.
It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.
A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).
I knocked on the door and reached for the doorknob.
As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.
I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.
He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.
Post-Meeting Blues
I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.
As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:
I should have asked him if he had family.
I should have asked him who his gastroenterologist was.
I should have called his gastroenterologist.
I should have put a hand on his shoulder and told him we would figure this out together.
I should have told him he wasn’t alone.
I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.
I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.
I’m So Glad To See You
Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.
Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.
I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.
Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.
To me, that day was the day I joined the medical profession.
I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.
Lessons Learned
To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.
There are three lessons that I’ll never forget in my practice of hospital medicine:
Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.
If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.
Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.
Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.
Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.
“Are you comfortable talking to him about all this stuff?” my attending asked me casually.
“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.
STOP!
Hold on. What did I just agree to do?
More than a decade later, I still feel the nervous tension in my stomach as I think about that day.
It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.
A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).
I knocked on the door and reached for the doorknob.
As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.
I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.
He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.
Post-Meeting Blues
I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.
As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:
I should have asked him if he had family.
I should have asked him who his gastroenterologist was.
I should have called his gastroenterologist.
I should have put a hand on his shoulder and told him we would figure this out together.
I should have told him he wasn’t alone.
I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.
I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.
I’m So Glad To See You
Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.
Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.
I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.
Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.
To me, that day was the day I joined the medical profession.
I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.
Lessons Learned
To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.
There are three lessons that I’ll never forget in my practice of hospital medicine:
Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.
If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.
Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.
Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.
Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.
“Are you comfortable talking to him about all this stuff?” my attending asked me casually.
“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.
STOP!
Hold on. What did I just agree to do?
More than a decade later, I still feel the nervous tension in my stomach as I think about that day.
It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.
A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).
I knocked on the door and reached for the doorknob.
As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.
I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.
He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.
Post-Meeting Blues
I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.
As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:
I should have asked him if he had family.
I should have asked him who his gastroenterologist was.
I should have called his gastroenterologist.
I should have put a hand on his shoulder and told him we would figure this out together.
I should have told him he wasn’t alone.
I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.
I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.
I’m So Glad To See You
Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.
Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.
I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.
Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.
To me, that day was the day I joined the medical profession.
I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.
Lessons Learned
To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.
There are three lessons that I’ll never forget in my practice of hospital medicine:
Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.
If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.
Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.
Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.
Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.
Hospitalists Have Opportunity to Transform Healthcare
“I’m going to the sun,” my TWO-and-a-half-year-old daughter confidently declared. She said it so casually, as if she was letting me know that she was going to the playground.
Thinking I could use this as a great parenting opportunity and push my toddler to think through her decisions, I replied in a concerned tone: “Sweetie, the sun is really, really hot. What are you going to do about that?”
She replied effortlessly, as if the solution had always been right there in front of me, and somehow I had failed to see it, “I’m going to wear a really, really big hat!”
Later that night, I was reflecting on the little exchange with my daughter. Why had I been so determined to point out to her that it was impossible to travel to the sun? After all, two is the age to dream and imagine. As we grow up, why do we stop believing that we can do anything, absolutely anything, we imagine?
Since I started working as a hospitalist in 2007, the state of healthcare has been in constant turmoil and distress. Everyone, from providers to policymakers to patients, has been critical about the current state of our healthcare system. Many are concerned with the future, too. In fact, headlines regularly describe healthcare as “deficient,” “error-prone,” “deadly,” “bankrupt,” or “wasteful.”
This is not the vision of the medical profession that I had when I was an idealistic medical student. I was filled with aspirations of curing the sick, alleviating suffering, and helping to make the world a better place.
Don’t get me wrong...I get it. Hospitals, hospitalists, and all forms of care providers have a long way to go before we provide the highest quality of care at a cost our nation and our patients can afford. But in the critical evaluation of the current state of healthcare, where is the positive beacon of hope?
When did we, providers of care, stop believing that we could do anything, absolutely anything, to improve the state of healthcare?
Over the past decade, numerous innovations have been introduced to address the deficiencies in our system. However, efforts to come together as a medical profession and address these issues systematically have been lacking. And new initiatives, such as the ABIM Foundation’s Choosing Wisely campaign, are still in the early stages of widespread acceptance and adoption.
We have come a long way from the witchcraft of early healers and the barber-surgeons of medieval times. Modern medicine comes from a tradition of discovering the germ theory, eradicating polio, sequencing the entire genome, and performing simultaneous multiple organ transplantation. Providers are more than healers of the individual patient; they are healers of populations. By advancing health, they have enabled societies to thrive, grow, discover, and innovate. We shoulder significant responsibility, and our impact has shaped the course of human history.
Despite the stated challenges in healthcare, I’d like to think this is our finest hour, our time to shine. We have a rare and unique opportunity to completely reinvent the system and redefine the practice of medicine—to transform it from how it is practiced to how it should be delivered: high quality, high value, patient-centered, yet population-focused. This goes beyond ensuring that every patient with acute myocardial infarction receives an aspirin or working to prevent surgical site infections. This opportunity affords us the possibility to deliver extraordinary care.
Can hospitalists bridge this gap and change the world? Absolutely!
Inherent in our work is continuous improvement, not solely the improvement of our specialty, but also of the services we help co-manage, the hospital-wide committees we sit on, and the C-suite conversations we partake in. And, unlike most of healthcare, we manage to do this, not in isolation, but in multidisciplinary teams of physicians, nurses, staff, and, most importantly, patients and families.
If we unleash the potential of our specialty, the possibilities are endless. Here are some examples from our own hospitalists and society:
- Imagine the future of care with mentored implementation.
SHM’s award-winning mentored implementation model has helped transform care in more than 300 hospitals through best practices in venous thromboembolism, readmissions, and care of diabetic patients.
- Lead with the academy.
The future of healthcare will belong to clinicians who can lead teams and make the case for real change. That’s one of the reasons that SHM’s Leadership Academy has been so successful: It is creating a cadre of more than 2,000 hospitalists who are armed with the confidence and know-how to envision the hospital of the future and manage hospital-based teams toward that vision.
- Collaborate with HMX.
If you’ve ever been to SHM’s annual meeting, you know that hospitalists are a collaborative bunch. In fact, it’s that tendency toward collaboration and problem solving that has led more than 2,300 hospitalists to participate in SHM’s new online community, Hospital Medicine Exchange (www.hmxchange.org). It’s unlike any other platform for hospital-based clinicians, and the conversations on HMX are helping hospitalists everywhere benefit from the experience of colleagues nationally.
- Learn through the portal.
Hospitalists can’t shape the future of healthcare without staying up to date, but the days of getting continuing medical education (CME) credit exclusively from conferences is over. SHM is helping hospitalists with its brand new eLearning Portal (www.shmlearningportal.org), which can be accessed on PCs, tablets, or mobile devices.
Expectation High
So, be bold! The sky is the limit. Continue to learn, collaborate, and lead. Most of all, never stop believing that you can create the future you imagine. After all, it was Albert Einstein who cleverly said, “Imagination is more important than knowledge.”
As for my daughter and I, well, I guess I’m going to start investing in really big hats.
Dr. Afsar is associate chief medical officer at UCLA Hospitals in Los Angeles. She is also assistant clinical professor and executive director of quality and safety in the Department of Medicine and Neurosurgery at UCLA Hospitals. She is an SHM board member. Contact her at nafsarmanesh@mednet.ucla.edu.
“I’m going to the sun,” my TWO-and-a-half-year-old daughter confidently declared. She said it so casually, as if she was letting me know that she was going to the playground.
Thinking I could use this as a great parenting opportunity and push my toddler to think through her decisions, I replied in a concerned tone: “Sweetie, the sun is really, really hot. What are you going to do about that?”
She replied effortlessly, as if the solution had always been right there in front of me, and somehow I had failed to see it, “I’m going to wear a really, really big hat!”
Later that night, I was reflecting on the little exchange with my daughter. Why had I been so determined to point out to her that it was impossible to travel to the sun? After all, two is the age to dream and imagine. As we grow up, why do we stop believing that we can do anything, absolutely anything, we imagine?
Since I started working as a hospitalist in 2007, the state of healthcare has been in constant turmoil and distress. Everyone, from providers to policymakers to patients, has been critical about the current state of our healthcare system. Many are concerned with the future, too. In fact, headlines regularly describe healthcare as “deficient,” “error-prone,” “deadly,” “bankrupt,” or “wasteful.”
This is not the vision of the medical profession that I had when I was an idealistic medical student. I was filled with aspirations of curing the sick, alleviating suffering, and helping to make the world a better place.
Don’t get me wrong...I get it. Hospitals, hospitalists, and all forms of care providers have a long way to go before we provide the highest quality of care at a cost our nation and our patients can afford. But in the critical evaluation of the current state of healthcare, where is the positive beacon of hope?
When did we, providers of care, stop believing that we could do anything, absolutely anything, to improve the state of healthcare?
Over the past decade, numerous innovations have been introduced to address the deficiencies in our system. However, efforts to come together as a medical profession and address these issues systematically have been lacking. And new initiatives, such as the ABIM Foundation’s Choosing Wisely campaign, are still in the early stages of widespread acceptance and adoption.
We have come a long way from the witchcraft of early healers and the barber-surgeons of medieval times. Modern medicine comes from a tradition of discovering the germ theory, eradicating polio, sequencing the entire genome, and performing simultaneous multiple organ transplantation. Providers are more than healers of the individual patient; they are healers of populations. By advancing health, they have enabled societies to thrive, grow, discover, and innovate. We shoulder significant responsibility, and our impact has shaped the course of human history.
Despite the stated challenges in healthcare, I’d like to think this is our finest hour, our time to shine. We have a rare and unique opportunity to completely reinvent the system and redefine the practice of medicine—to transform it from how it is practiced to how it should be delivered: high quality, high value, patient-centered, yet population-focused. This goes beyond ensuring that every patient with acute myocardial infarction receives an aspirin or working to prevent surgical site infections. This opportunity affords us the possibility to deliver extraordinary care.
Can hospitalists bridge this gap and change the world? Absolutely!
Inherent in our work is continuous improvement, not solely the improvement of our specialty, but also of the services we help co-manage, the hospital-wide committees we sit on, and the C-suite conversations we partake in. And, unlike most of healthcare, we manage to do this, not in isolation, but in multidisciplinary teams of physicians, nurses, staff, and, most importantly, patients and families.
If we unleash the potential of our specialty, the possibilities are endless. Here are some examples from our own hospitalists and society:
- Imagine the future of care with mentored implementation.
SHM’s award-winning mentored implementation model has helped transform care in more than 300 hospitals through best practices in venous thromboembolism, readmissions, and care of diabetic patients.
- Lead with the academy.
The future of healthcare will belong to clinicians who can lead teams and make the case for real change. That’s one of the reasons that SHM’s Leadership Academy has been so successful: It is creating a cadre of more than 2,000 hospitalists who are armed with the confidence and know-how to envision the hospital of the future and manage hospital-based teams toward that vision.
- Collaborate with HMX.
If you’ve ever been to SHM’s annual meeting, you know that hospitalists are a collaborative bunch. In fact, it’s that tendency toward collaboration and problem solving that has led more than 2,300 hospitalists to participate in SHM’s new online community, Hospital Medicine Exchange (www.hmxchange.org). It’s unlike any other platform for hospital-based clinicians, and the conversations on HMX are helping hospitalists everywhere benefit from the experience of colleagues nationally.
- Learn through the portal.
Hospitalists can’t shape the future of healthcare without staying up to date, but the days of getting continuing medical education (CME) credit exclusively from conferences is over. SHM is helping hospitalists with its brand new eLearning Portal (www.shmlearningportal.org), which can be accessed on PCs, tablets, or mobile devices.
Expectation High
So, be bold! The sky is the limit. Continue to learn, collaborate, and lead. Most of all, never stop believing that you can create the future you imagine. After all, it was Albert Einstein who cleverly said, “Imagination is more important than knowledge.”
As for my daughter and I, well, I guess I’m going to start investing in really big hats.
Dr. Afsar is associate chief medical officer at UCLA Hospitals in Los Angeles. She is also assistant clinical professor and executive director of quality and safety in the Department of Medicine and Neurosurgery at UCLA Hospitals. She is an SHM board member. Contact her at nafsarmanesh@mednet.ucla.edu.
“I’m going to the sun,” my TWO-and-a-half-year-old daughter confidently declared. She said it so casually, as if she was letting me know that she was going to the playground.
Thinking I could use this as a great parenting opportunity and push my toddler to think through her decisions, I replied in a concerned tone: “Sweetie, the sun is really, really hot. What are you going to do about that?”
She replied effortlessly, as if the solution had always been right there in front of me, and somehow I had failed to see it, “I’m going to wear a really, really big hat!”
Later that night, I was reflecting on the little exchange with my daughter. Why had I been so determined to point out to her that it was impossible to travel to the sun? After all, two is the age to dream and imagine. As we grow up, why do we stop believing that we can do anything, absolutely anything, we imagine?
Since I started working as a hospitalist in 2007, the state of healthcare has been in constant turmoil and distress. Everyone, from providers to policymakers to patients, has been critical about the current state of our healthcare system. Many are concerned with the future, too. In fact, headlines regularly describe healthcare as “deficient,” “error-prone,” “deadly,” “bankrupt,” or “wasteful.”
This is not the vision of the medical profession that I had when I was an idealistic medical student. I was filled with aspirations of curing the sick, alleviating suffering, and helping to make the world a better place.
Don’t get me wrong...I get it. Hospitals, hospitalists, and all forms of care providers have a long way to go before we provide the highest quality of care at a cost our nation and our patients can afford. But in the critical evaluation of the current state of healthcare, where is the positive beacon of hope?
When did we, providers of care, stop believing that we could do anything, absolutely anything, to improve the state of healthcare?
Over the past decade, numerous innovations have been introduced to address the deficiencies in our system. However, efforts to come together as a medical profession and address these issues systematically have been lacking. And new initiatives, such as the ABIM Foundation’s Choosing Wisely campaign, are still in the early stages of widespread acceptance and adoption.
We have come a long way from the witchcraft of early healers and the barber-surgeons of medieval times. Modern medicine comes from a tradition of discovering the germ theory, eradicating polio, sequencing the entire genome, and performing simultaneous multiple organ transplantation. Providers are more than healers of the individual patient; they are healers of populations. By advancing health, they have enabled societies to thrive, grow, discover, and innovate. We shoulder significant responsibility, and our impact has shaped the course of human history.
Despite the stated challenges in healthcare, I’d like to think this is our finest hour, our time to shine. We have a rare and unique opportunity to completely reinvent the system and redefine the practice of medicine—to transform it from how it is practiced to how it should be delivered: high quality, high value, patient-centered, yet population-focused. This goes beyond ensuring that every patient with acute myocardial infarction receives an aspirin or working to prevent surgical site infections. This opportunity affords us the possibility to deliver extraordinary care.
Can hospitalists bridge this gap and change the world? Absolutely!
Inherent in our work is continuous improvement, not solely the improvement of our specialty, but also of the services we help co-manage, the hospital-wide committees we sit on, and the C-suite conversations we partake in. And, unlike most of healthcare, we manage to do this, not in isolation, but in multidisciplinary teams of physicians, nurses, staff, and, most importantly, patients and families.
If we unleash the potential of our specialty, the possibilities are endless. Here are some examples from our own hospitalists and society:
- Imagine the future of care with mentored implementation.
SHM’s award-winning mentored implementation model has helped transform care in more than 300 hospitals through best practices in venous thromboembolism, readmissions, and care of diabetic patients.
- Lead with the academy.
The future of healthcare will belong to clinicians who can lead teams and make the case for real change. That’s one of the reasons that SHM’s Leadership Academy has been so successful: It is creating a cadre of more than 2,000 hospitalists who are armed with the confidence and know-how to envision the hospital of the future and manage hospital-based teams toward that vision.
- Collaborate with HMX.
If you’ve ever been to SHM’s annual meeting, you know that hospitalists are a collaborative bunch. In fact, it’s that tendency toward collaboration and problem solving that has led more than 2,300 hospitalists to participate in SHM’s new online community, Hospital Medicine Exchange (www.hmxchange.org). It’s unlike any other platform for hospital-based clinicians, and the conversations on HMX are helping hospitalists everywhere benefit from the experience of colleagues nationally.
- Learn through the portal.
Hospitalists can’t shape the future of healthcare without staying up to date, but the days of getting continuing medical education (CME) credit exclusively from conferences is over. SHM is helping hospitalists with its brand new eLearning Portal (www.shmlearningportal.org), which can be accessed on PCs, tablets, or mobile devices.
Expectation High
So, be bold! The sky is the limit. Continue to learn, collaborate, and lead. Most of all, never stop believing that you can create the future you imagine. After all, it was Albert Einstein who cleverly said, “Imagination is more important than knowledge.”
As for my daughter and I, well, I guess I’m going to start investing in really big hats.
Dr. Afsar is associate chief medical officer at UCLA Hospitals in Los Angeles. She is also assistant clinical professor and executive director of quality and safety in the Department of Medicine and Neurosurgery at UCLA Hospitals. She is an SHM board member. Contact her at nafsarmanesh@mednet.ucla.edu.