So God created mankind in his own image,
in the image of God he created them;
male and female he created them.
Genesis 1:27 New International Version
Years ago, when I was a freshman at Stanford, I acted in a few college plays. One of my favorite roles was E.K. Hornbeck, the cynical wise-cracking reporter in Jerome Lawrence and Robert E. Lee’s drama Inherit the Wind,1 about the Scopes “Monkey” trial of 1925. In this landmark case, John Scopes, a schoolteacher was put on trial for teaching Darwinian evolution in a Tennessee high school, spurring a national conversation on the role of religion versus science in public education.
In the very last scene of the play in the narrowing beam of a spotlight, the Clarence Darrow character, Henry Drummond, picks up a copy of The Origin of the Species by Darwin in one hand and the Holy Bible in the other. Like a human balance scale, he hefts aloft each book, arms outstretched, and compares them briefly. He then dramatically slaps them together before dropping them both side by side in his briefcase – the spotlight fades to black. It is a very satisfying theatrical moment, but what is it actually trying to say?
With all due respect to the Bible, and not to be blasphemous, in my mind, there is no comparison. If man was created in the exact image of God, so many things need to be explained away. For example, why the appendix?
As a physician who spends an inordinate amount of time at all hours of the day and night anesthetizing patients for appendectomies, I have strong opinions about creationism versus evolution by natural selection. If I had to choose just one anatomical example in favor of Mr. Darwin, it would most certainly be the human appendix.
Of all the ill-tempered, crazy things that the God of Abraham is credited for having intentionally done in Genesis 1:27, placing this useless and trouble-making stump of flesh at the beginning of our colon has to be near the top of the list.
In our ancient pre-hominid incarnation as small ground-dwelling mammals, the appendix may have played a more useful role, as it does in modern-day rabbits, rodents, and other such buck-toothed chewing machines.
There are several theories about what the appendix actually does. One theory posits that the appendix is a reservoir of beneficial bacteria, allowing mammals to ingest a variety of fibrous and impossible-to-digest foods.
More recent research has discovered that the appendix contains a large collection of specialized lymphoid tissue, perhaps mediating intestinal immunity against pathogens. Despite this potentially rehabilitating bit of information, the relentless march of genetic progress via natural selection, random as it is, has largely relegated the human appendix, along with other vestigial structures such as the coccyx, the erector pilae muscles, and the plica luminaris2 to the trash heap of human appurtenances. Most people do quite well without it.
It would be nice if the appendix just minded its own business, and quietly did whatever lymphatic thing it is doing and didn’t trouble us, or just continued to simply fade away into non-existence. But like an unsolicited sales call, or worse a Nigerian Prince phone scam, it occasionally and most inconveniently interrupts an otherwise pleasant trouble-free life by making its presence uncomfortably and sometimes dangerously known.
Appendicitis is a medical condition in which the appendix becomes infected and inflamed. Many people will develop appendicitis at one point or another in their lifetime. About 250,000 cases of appendicitis3 occur annually in the United States. The lifetime risk of an appendectomy is estimated at 12% for males and 23% for females. It typically affects those under thirty, however, it may occur at any age.
Historically, the diagnosis of an inflamed and burst appendix was often a death sentence. Its rupture causes exposure of the contents of the bowel to the unprotected inside of the abdomen resulting in a condition known as peritonitis. This can lead to overwhelming sepsis,4 a critical life-threatening situation due to a breakdown of the protective lining of the intestine and gut bacteria entering the bloodstream.
Related Content: Early Diagnosis of Sepsis is the Key to Saving Lives
Prior to the invention of powerful antibiotics, sepsis was almost always fatal. Even with the wide variety of medications available today, including antibiotics, blood pressure supporting medications, and ICU care, sepsis is still a leading cause of death in hospitalized patients. Fortunately, most cases of appendicitis are caught well before the appendix ruptures. With timely diagnosis and treatment, appendicitis is an easily treated medical problem – usually surgically.
The first recorded appendectomy was performed in 1736 by the French surgeon, Claudius Aymand, who operated on an awake eleven-year-old for an appendix perforated by a swallowed straight pin. In 1804, the only person to die on the entire Lewis and Clark expedition was Sergeant Charles Floyd,5 due to an attack of suspected appendicitis. At this time surgical anesthesia did not exist save for a shot of whiskey and a stick to bite on, nor did reliable intra-abdominal surgery. There were certainly no antibiotics to be had at any price. It wasn’t until the latter part of the 19th century with the advent of general anesthesia and more refined surgical techniques that it was possible to treat and cure appendicitis.
In my family, both my wife and my daughter have had appendicitis followed by emergency surgery. Dana had hers in the first trimester of her third and last pregnancy with our youngest and only daughter Kate. She, in turn, had her bout of appendicitis at the tender age of four.
Dana’s appendicitis went something like this – She woke up in the middle of the night with nausea and a vague pain around the area of her belly button. She jostled me awake to tell me about it. Given that she was pregnant, I wasn’t too concerned, as it is pretty normal to have a variety of abdominal complaints in the first trimester. I do remember being tired and cranky, however. “It’s just gas, go to sleep!” I grumpily said before I rolled over and fell asleep.
But Dana could not sleep. Despite sitting in a warm bath for the rest of the night, she felt worse in the morning. She vomited once and her pain had now moved to the right lower side of her abdomen. She did say she felt a little better after throwing up. This re-assured me despite the fact that the pain of appendicitis sometimes improves a bit before the condition gets much worse. Deep down I knew this, which brings me to the three “D”s of diagnosis
As is the case in many doctor’s families, these three “D’s” are the hallmarks of identifying any domestic medical problems that may arise.
More from this author:
Pediatric Airway Emergency! An Anesthesiologist’s Life, a Father’s Nightmare
An Anesthesiologist Learns the ‘Facts’ about Epidurals in Childbirth Class
The first “D” is “downplaying” the complaint. “Are you sure you’re really sick? Cause a lot of my patients are, and you don’t seem that sick to me…” This is a common phrase heard in mine and many other physician houses, and I am sure my family is definitely sick of hearing it.
The second “D” is for denial. While for a brief second, I did consider that Dana’s constellation of symptoms might be appendicitis, I was far more worried about an ectopic pregnancy6 as that was entirely possible given her gestational age of ten weeks, a common time for such a problem.
The third and final “D” is for “Dummy”, which is what I called myself when Dana was actually diagnosed with a nearly ruptured appendix several hours later when I was long gone to the hospital and working on my own patients.
Rather than trusting my medical instincts and relying instead far too heavily on my personality of always looking at the bright side of things, I did in fact leave my pregnant, sick wife at home with two small boys to take care of.
It was not my proudest moment as a doctor, a father, and most certainly a husband. Fortunately, we have an amazing friend, Gina. We call her Saint Gina. She is a nurse and a super-mom, and as practical and able as they come. Soon after I had left for work, Dana called her to look after our boys because she was feeling too sick to get up. As soon as she arrived, Gina took one look at Dana and said, “You are going right to the hospital!”
In retrospect, it is good advice for physicians to leave the diagnosis and treatment of family members to others far more objective, and thus more competent. Once in the emergency room at the hospital, a surgical consult and an ultrasound of Dana’s abdomen revealed both a healthy intrauterine pregnancy and a grossly swollen appendix ready to burst. In many cases, a CT scan is also indicated, but this was held due to the fact that she was pregnant.
Most appendectomies are done using laparoscopic surgery7 under general endotracheal anesthesia. Dana underwent an uneventful open appendectomy under spinal anesthesia in order to minimize both exposure to systemic anesthetic agents and to perform the surgery with as little disruption as possible to our developing fetus that eventually became our lovely daughter Kate.
Dana chatted comfortably throughout the surgery with the anesthesiologist, one of my partners at UCSF, and she recovered perfectly. Six months later Kate was born, a healthy and beautiful baby girl. As luck would have it, young Kate would soon follow in her mother’s footsteps.
Early one evening when she was four years old, we decided to see “Harry Potter and the Chamber of Secrets” at our local theatre. She had been feeling a little poorly for most of that day and was a touch irritable. For Kate, irritable meant that she smiled only most of the time rather than always. So I thought a movie would cheer her up, and off we went.
She sat through the movie about young wizards and witches “spellbound” with the film. But, I do remember noticing that her hand seemed a little warm to the touch. And she wiggled around in her seat every now and then like she was trying to find a more comfortable position. I also saw her grimace and stiffen a few times when she did move.
What really got my attention, however, was that she turned down an offer of candy and popcorn. Then, I knew something was really wrong. As we walked up the aisle at the end of the movie, she walked a little stiff-legged and was unusually quiet. By the time we got home, I could tell she felt sick.
I laid her down on the couch in the family room and proceeded to play surgeon. “Does your tummy hurt?” I asked. She nodded. “First it hurt all over and now it hurts here.” She pointed at the spot in the lower right corner of her abdomen called “McBurney’s point”8 named after the surgeon who initially described the signs of appendicitis. Textbook answer.
“Does it hurt more when I press, or when I let go?” I gently pushed then released the spot to which she pointed. She winced as I let go. This sign indicates an inflamed appendix and a resultant sensitive peritoneum, the lining of the abdominal cavity. With a sinking feeling, I knew we were going to the hospital. I could fool myself once, but not twice.
It was now late in the evening, and the emergency waiting room at our local hospital was totally empty. Literally, crickets. Nevertheless, we sat there on the hard plastic chairs under the harsh glare of the fluorescent lights for what seemed to be an eternity.
Finally, I couldn’t take it anymore and in my best doctor voice using every bit of medical jargon I could muster, approached the intake nurse and said, “Listen, my daughter is febrile, has peri-umbilical pain that has localized to the right lower quadrant, has rebound tenderness and is guarding. Could we please see the doctor on call – now?” The last word “now” was perhaps a little too emphatic and surgeon-like.
She looked at me, her expression narrowed, and with a voice dripping with condescension said, “My! We are using big medical words, aren’t we? Are we a nurse or something?” I resisted the urge to escalate and replied in as level a Clint Eastwood voice as possible, “No, we are a doctor or something. Should I use smaller non-medical words?” I was being a total jerk but I didn’t care. This was my daughter after all.
Once in the ER, a quick urine test was negative for infection and a blood test revealed a high white blood cell count. Ultrasound again clinched the diagnosis. Kate was a trooper through it all, bravely enduring a urethral straight catheter and a needle poke for a blood sample without so much as a whimper.
Because our local hospital had neither pediatric surgeons nor dedicated pediatric anesthesiologists and I must admit, I felt more comfortable on my home turf, I called my friend, Mike Harrison,9 one of the best pediatric surgeons in the country, who came in from home and saw her immediately in the ER at UCSF as soon as we got there.
The surgery was quick and went well. Her appendix was nearly ruptured, but like Dana’s, we caught it in time. I remember thinking to myself during that agonizing wait after the anesthesiologist put her to sleep in my arms, and the hour or so later when I saw her in the recovery room, that I was so lucky to live in an area with so much choice and talent available. Also, that I had good insurance, had the ability to help manage her care, and to be there for my daughter. Not everyone in this country is as fortunate and I knew that full well.
It is truly amazing that such a small, insignificant vestigial tube of flesh can cause so much trouble, but it most certainly does. Dana remembers her appendectomy as the time that our two boys, then age two and four were given free rein in the kitchen and on the computer.
As she lay in bed suffering waiting for St. Gina to arrive, her doctor husband was taking care of his own patients instead of his ailing wife. Unsupervised, they went to town on the snack drawer and primed with sugar, they printed hundreds of pictures of Pajama Sam, Sly Fox, and Putt-Putt the talking car,10 heroes of their favorite “Humongous Entertainment” games.
Kate remembers enjoying the escapades of Harry Potter and especially Hermione Grainger a lot despite the pain in her stomach. She vividly remembers her late-night trip to the hospital where daddy worked and the popsicles after surgery.
I remember being humbled and so thankful that we live in a time and place where we have immediate access to such wondrous medical technology, that we have amazing and supportive friends and colleagues, and that an appendectomy is considered minor surgery. Though perhaps I should reconsider that final thought, as minor surgery is always something that happens to someone else.
What is sepsis? Centers for Disease Control and Prevention
Charles Floyd (explorer) (1782 – August 20, 1804). Lewis and Clark Expedition. Wikipedia. httpss://en.wikipedia.org/wiki/Charles_Floyd_(explorer)
Appendectomy, Treatments, Tests, and Therapies. John Hopkins Medicine. httpss://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/appendectomy
We live in an old chaos of the sun,
Or old dependency of day and night,
Or island solitude, unsponsored, free,
Of that wide water, inescapable.
Deer walk upon our mountains, and the quail
Whistle about us their spontaneous cries;
Sweet berries ripen in the wilderness;
And, in the isolation of the sky,
At evening, casual flocks of pigeons make
Ambiguous undulations as they sink,
Downward to darkness, on extended wings.
Wallace Stevens, Sunday Morning1, Stanza viii
The Collected Poems, 1954
The first time I ever saw a dead person was in 1971. It was at the Thomas P. Kearney Funeral Home on North Main Street in Old Forge, Pennsylvania.2 I was attending the wake the evening before the funeral of my mother’s first cousin Alex. We called him Uncle Al.
He was the golden son of our large immigrant family who journeyed from the hill villages of Campania in southern Italy over a hundred years ago. From the seaside ports of Naples, they boarded passenger liners, tramp steamers, and sooty cargo ships fleeing poverty and famine.
They crossed the Mediterranean and the cold Atlantic to Ellis Island3 in New York harbor. From there they made their way to the anthracite coal seamed hills of eastern Pennsylvania with all of their possessions packed in battered trunks and suitcases. This was a destination far from the shadow of Vesuvius and the terraced hillsides of sunbaked stone and olive trees.
Alex was the embodied exclamation point of untold generations of our old-country ancestors. He was the first to go to college, and then medical school. He became a doctor, rather than a laborer, stonemason, or coal miner.
He was the pride not only of his parents and his many aunts, uncles, and cousins but of the entire town that collectively and proudly claimed him as their own. In a cruel twist of fate, Alex died suddenly of a heart attack in his early forties in a family filled with old people.
It is a tradition among Italian-American Catholics to have a wake, an open casket viewing prior to the funeral. This is where I saw him on a bier surrounded by massive bouquets of white flowers.
Here was his final bed. His head rested on a satin pillow, dressed in his sharpest suit, the one he wore to Sunday mass and to the hospital to round on his many loyal patients.
At this time of my life, I was a small, quiet, and serious boy. I was made more so by the untimely death of my own father three years earlier from a sudden ruptured cerebral aneurysm4 at the tragically premature age of thirty-four.
My father was a young doctor as well, the eldest son and the pride of his own West Virginia family. So, this ritual, my second cousin’s viewing, promised me something already familiar yet at the same time forbidding and unworldly.
I never went to my father’s funeral. The last time I ever saw him, he was being wheeled down our upstairs hallway on a white ambulance stretcher. He was semi-conscious, with his head lolling from side to side like a parody of a drunkard in a cartoon.
I had woken up early that sunny January morning in 1968. I remember there was frost on the windows looking out over the large circular driveway of the old Long Island estate in Roslyn Harbor5 where my family lived in a red brick carriage house with black shutters.
My mother was downstairs making breakfast in the kitchen. When she was done setting the table, she told me to go wake up my father. He had returned from a late-night call shift at the hospital where he worked as an anesthesiologist, a Lieutenant Commander in the Navy.
I remember taking the stairs two at a time and then heading down the hall, my fingers tracing the wall past my sister’s bedroom, then my brother’s and mine. I went past the bathroom that was still damp and warm from a shower my mother had taken that morning.
Slowly, I reached out for the brass doorknob of my parent’s room at the end of the hall and turned it, only to find the door locked. This caught me by surprise. Their door was never locked. I twisted it right and left, knocked, and knocked again. Then, I rattled the door, shouting for my dad to wake up. He didn’t answer.
My memory is unreliable after that and recalling these events feels more like a story told to me by someone else. I do remember my mom thinking at first it was funny, that he was playing a joke on us.
She then became being annoyed, and angrily came upstairs and began slapping, then pounding on a door that would not open. Her anger was replaced by panic. She ran back downstairs and called the neighbors, Mr. and Mrs. Best, who quickly came over.
They called the firemen who arrived in their red engine, flashing lights, and a wailing siren. They in turn called the ambulance after breaking through the door and finding him in bed, unresponsive. I can still hear my mom screaming his name, pleading with him to wake up.
For two weeks he was in a hospital6 in Glen Cove where I was not allowed to go. My relatives from Old Forge and Morgantown came over the next few days and clustered in the den and living room of our house.
They reminded me of the groups of dark shorebirds down at the beach at Mott Cove, a short walk down the hill. Their heads bobbed together, and they moved in groups speaking in hushed whispers and occasional cries. It seemed to me that they could not look directly at me without giving away a secret I couldn’t even begin to guess.
I do remember very clearly the morning my mother called me to her room, and stiffly and awkwardly told me he had died. She tried her best to maintain her composure and lost that battle. Her chin tilted back, her voice stuttered and halted. “Your father is gone.” The final, awful word “gone” broke into a high-pitched dissonant cry. Gone where? I was so sad and confused. I didn’t know, and I didn’t want to find out.
So, I refused to go to the funeral. Instead, I stubbornly hid under the front entry hall table as small clutches of women in black dresses, and men in dark suits and skinny ties passed me again and again. They knelt down and tried to coax me out but nothing on earth would move me.
The neatly creased triangular folded American flag that draped his casket sat untouched on that same table for weeks afterward. It was finally packed away in a cardboard box with the rest of his possessions and disappeared with most everything else that belonged to him in the years and many moves that followed.
It was with a mixture of dread and curiosity that I approached the white satin-lined casket of Uncle Alex surrounded with flowers. It exuded a cloying sickly-sweet smell mixed with some other musty odor that I could not place.
“Our Al”, is what my Grandmother and her four sisters called him. He was the eldest son of my Great Aunt Rose, the youngest daughter of the five Fabbo sisters. Her husband, my Great Uncle Tony was a painter who whistled Italian melodies while he worked putty into cracks in wood and sang in a warbling tenor as he painted.
Uncle Tony was once an entertainer, a guitar player who cherished his battered Martin guitar and serenaded lovers in dark restaurants and speakeasies. He often boasted that he once crooned a ballad called The Roses of Picardy7 for Al Capone.
Faded framed nightclub posters of him on the walls of his house attested to his once slick Valentino good looks. Now his perpetually smiling face was gone, replaced with a terrible visage of the utter and abject grief of a man who had outlived his only son.
The dead body was unreal to me, more waxworks than flesh. His neatly manicured clay-like fingers seemed firmly squared and unnaturally creased rather than soft and rounded. They were entangled with black rosary beads. A silver cross with a small figure of a dying Christ stared back at me.
I carefully watched his chest for what seemed like an eternity, but it did not move. I held my breath to see if I could keep mine as still, but failed, and exhaled loudly. His face was impassive, his thin eyelids were closed, somehow him and not him, not the Uncle Alex that I knew, but something else.
I must have stopped at the casket mesmerized at the sight of his body for a long time, because I remember stirring as if from a dream, suddenly aware of the unyielding presence and pressure of the living, bustling, powdered flesh behind me. They were pushing me forward towards the black receiving line of his immediate family who was waiting to receive condolences from the perfumed, and furred mourners stretching out into the hall, and beyond.
I attended many funerals after that, most in that same small town of Old Forge, where the old world of my family slowly disappeared. Next to leave was my Grandfather, then my Great Aunts Caroline and Sylvia, and Uncle Tony. Next were cousins that I barely knew, and old Italian men named Pecker, and the Duck, and Razor.
These were men who played pinochle, went to prize-fights at the Scranton CYC, stood on corners and smoked cigars. They were men who faded, grew old, and died…
And then it was my precious Grandma’s turn – the woman who helped raise me after my father died. She cooked me “pasta fazool” and rolled out macaroni and Christmas cookies on her kitchen table and called shrimp “shrimps.”
She let me pat her stiff hair-sprayed head while she laughed and laughed, always “worried” about me. Grandma hugged me hard at comings and goings. She loved me fiercely and unconditionally.
And then I moved on. I came to California, and a different world, far from the low rolling hills, and the dusty coal town of my mother’s family.
Years later I saw my next dead body. In truth, it was two dead bodies, but one I watched die. I didn’t exactly know it then, but the experience was the catalyst that caused me to pause and re-examine and re-direct my life.
For four summers I worked at the Stanford Sierra Camp8 at Fallen Leaf Lake, California. In my first summer there I was a counselor. I shepherded the three- and four-year-old “munchkins”, as their parents hiked, relaxed, and sipped wine on the deck of the old lodge. They reminisced about their carefree undergraduate days that I was still happily living.
My sense of humor was edgy, and definitely at times inappropriate. For the Fourth of July parade, I dressed up the children as Western settlers. They dutifully marched behind a covered wagon I had built out of a wooden cart, some PVC pipe, and bedsheets. It had the words “Daring Pioneers” written on the side of the wagon facing the parents. Facing the staff on the other side of the camp road were the words,“ Donner Party at Snack-Time. The hands of the munchkins were clutching and munching on chicken drumsticks.
As my fourth summer at camp after my college graduation turned to fall, I remained there working the conference season. I had no long-term plans and was, to be honest, somewhat lost. I had no idea what I wanted to be or even where I wanted to go next.
Fall became colder, and an early October snowfall dusted Angora ridge and the road around the lake. I was in the front office when a call came from a lakeside homeowner. Two fishermen had capsized and were struggling in the frigid water at Craven’s dock opposite our camp. My friend Rick and I grabbed the first aid kit and keys to one of the Country Squire station wagons and then slipped and skidded our way around Fallen Leaf Lake road.
We arrived to find the two heavy late middle-aged men chest-deep in the freezing water off the end of the dock. Their aluminum rowboat was overturned, their cooler and tackle-box bobbed beside them.
One man was frighteningly still, his face an ugly purple, his yellow-rimmed eyes open and fixed on some distant horizon. His arms extended limply to either side, a literal dead man’s float.
His companion heaved great gasps next to him, oblivious to our presence. We pulled both men from the water with considerable effort and laid them on the dock. Like his friend, the second man’s face soon turned mottled and dusky. His breathing became shallow and rapid.
Both Rick and I had taken CPR, and fumbled ahead, our cold numbed hands shaking. We checked his pulse. It was faint and thready, without the familiar rhythm of a normal heartbeat. As Rick began chest compressions, I leaned down to administer two rescue breaths into his gaping mouth, and then he retched.
Copious pea-green vomit snaked out of his throat and mouth with every thrust on his chest. I felt sick and gagged on my own rising bile. We continued CPR until the paramedics arrived and told us to stop. So, we stepped back, exhausted, allowing the reality and finality of the situation to sink in. Our prodigious efforts were in vain.
I remember clearly thinking to myself that this was a turning point. I wanted to know more, to be more competent and effective – to help. And for the first time in my life, I became fully aware of what I needed to do, and who I wanted to become.
I have seen many dead bodies since that snowy day at the lake. I practically lived with one during my first year in medical school in the anatomy lab. We named our cadaver Ernest, and would say we were always working in “dead Ernest.”
I am certain we did not invent that joke, but we always ridiculously enjoyed its repetition. Despite our wary familiarity with death, and our brave but often futile attempts to ward it off, physicians never entirely get used to it. Death remains an intruder, an unwelcome guest. At times, in some patients, death is inevitable. In others, it is an epic failure.
What has stayed with me most throughout my life as a doctor, since that fateful day on the lake and the years of study and training that followed, is an awareness born from actually seeing someone pass from the world we know into one we don’t.
In this fleeting moment, it’s hard not to believe in a soul. It is impossible to describe this ineffable feeling, but I remember a fragment of a poem I read in college whose authorship escapes me. In it, the poet describes the last moments of her dying father. She describes his mouth as “the size of a silver dollar with the dollar gone.” For me, that metaphor of emptiness and lost value says so much more than I will ever know.
***
Old Forge, Lackawanna County, Pennsylvania. Wikipedia httpss://en.wikipedia.org/wiki/Old_Forge,_Lackawanna_County,_Pennsylvania
Intracranial aneurysm, Wikipedia httpss://en.wikipedia.org/wiki/Intracranial_aneurysm
Roslyn Harbor, New York, Wikipedia httpss://en.wikipedia.org/wiki/Roslyn_Harbor,_New_York
We are such stuff
As dreams are made on; and our little life
Is rounded with a sleep.
Shakespeare, The Tempest Act IV, sc. 1, 156-158
I imagine a “rounded” sleep is a smooth and easy one, devoid of rough awakenings. It would be nice if my dreams were “rounded with a sleep,” but mine are jagged ones. And, more often than not, they are about my work. It is the particularly stressful operating room cases I revisit again and again in recursive loops of dread late into the night.
I am an anesthesiologist practicing in San Francisco, providing care at several hospitals and surgery centers. It was at the old Children’s Hospital that this terrifying tale of a pediatric airway emergency took place.
To this day, I dream of this case even though it happened many years ago. The memory of it will startle me awake. It troubles my thoughts and makes my heart race. My breaths come sharp and quick until I calm myself and sink into my pillow. Then, I try to go back to sleep before the morning arrives far too early and far too soon.
The buzz of activity of a well-run operating room is a sight to behold. Wheeled carts laden with packs of instruments wrapped in sterile blue paper are delivered by attendants straight from the autoclave. Machines and monitors, X-Ray C-arms, and operating microscopes are ferried from one room to another.
Surgeons, nurses, and scrub techs walk briskly and purposefully down the corridors dressed in blue-green scrubs and cover-gowns in a coordinated and efficient dance. Patients come and go, shepherded safely from awake to asleep to awake again in precise fashion by the anesthesiologists at the head of each OR bed.
On this particularly busy day in the middle of the afternoon, the operating rooms were in full swing, filled with the usual variety of elective cases. In Room 1, there were urology cases. Rooms 6 and 7 were booked with orthopedics, and Room 9 held a long list of breast biopsies. I was in Room 2 doing pediatric ENT cases – ear tubes, adenoids, and tonsillectomies. In my dreams, I am transported back to that room…
The list of elective surgeries diminishes as one after another is completed and erased from the master schedule-board. It is a smooth human assembly line as patients walk over from Admitting and are ushered into the holding area. They wait, dressed only in their paper, ill-fitting Bair-Hugger gowns1, to be seen by the circulating nurses and the anesthesiologists before entering the OR.
The gowns are ugly but effective, and they are disposable. They are a distinct improvement over the traditional tied-in-the-back, thin cotton gowns. These are designed to allow hot air from an external blower to circulate throughout the gown in built-in baffles, enveloping the patient in warmth to ward off the cold exposure of the operating room.
Late in the afternoon, the smooth routine of my day is disrupted. A call comes from the
emergency room that immediately puts a hold on my next scheduled case. A one-year-old child is being rushed directly from the ambulance bay to the OR for a foreign body airway obstruction.
This is unusual – I typically go down to the emergency room to evaluate the children first, but I am told that I don’t have time, as this one is in severe distress and already on the elevator.
With a sinking feeling, I run back to my room to prepare for the case. Beyond what I have just heard, I know nothing else. I don’t know what the child may have swallowed or how long he has been in trouble.
Even though I have been well trained for this exact situation, my stomach twists, my chest tightens, and I breathe a little faster, fearful that this may end badly.
Pediatric airway obstructions are emergencies of the highest order. Ask any anesthesiologist who is also a parent to pick their greatest fear while raising their young children. Mine was choking.
Despite an outward appearance of being calm and efficiently competent in emergencies, I can be a fairly anxious individual, especially where my family is concerned. They have had to endure countless lectures from me on the “forbidden” foods of childhood.
No raw carrots, peanuts, apples, hot dogs, steak, hard candy, and so forth, until the back molars are established, or the child has graduated from college, whatever comes last. And, definitely, no talking, laughing, singing, running, or walking around while eating.
Once at a birthday party for a friend of my eldest son, Henry, the other parents watched with both shock and embarrassment for me as I put a dramatic, hyperventilating, immediate end to a game of “Chubby Bunny.”2 If you have never heard of this game, consider yourself lucky. Chubby Bunny is a contest where the children compete to stuff as many marshmallows as possible in their mouth, one by one, and repeat the words “Chubby Bunny” three times.
To me, this game is tantamount to attempted child homicide. It is a prima facie example of gross parental neglect, justifying a call to Child Protective Services.
After startling all of the kids silent due to my sudden and very dramatic outburst, I made them immediately spit out the sticky gobs of marshmallow that were distending their cheeks like chipmunks.
I sarcastically and angrily asked the stunned host mother, “How about a game of
William Tell, or knife-throwing next? Do you have any Lawn Darts handy? Or let’s just tie up the kids and toss them in the pool to see which one can hold his breath the longest?” Obviously, it took a long time for me to be invited back to birthday parties after that.
From day one of residency, anesthesiologists are taught a simple algorithm: “ABC – Airway, Breathing, Circulation.” In pediatric anesthesiology, we are taught an even more succinct
algorithm: “AAA – Airway, Airway, Airway.”
It doesn’t take long to suffocate when the airway is obstructed. An adult has about three to four minutes after cessation of breathing room air before suffering irreversible brain damage. A toddler may have even less time due to the nature of their more rapid metabolism and high demand of the developing brain for oxygen.
This is why the importance of maintaining a patent airway in order to breathe is drilled into us before we even get to touch our first patient. A great deal of our knowledge and equipment is tailored to achieve this goal.
We learn how to assess an airway preoperatively to judge the potential risk of losing it once an anesthetic begins and the patient is rendered unconscious and unable to breathe unaided.
We know how to manipulate the jaw to tighten the neck muscles to support the pharyngeal structures and facilitate breathing.
And we know many ways to re-establish an airway once it’s lost, including performing an emergency cricothyroidotomy,3 literally cutting a hole in the neck. Mostly, we know how to do these things in a logical sequence, as rapidly as possible. Time is of the utmost essence.
Treatment of an airway obstructed by a foreign body can range from a simple slap on the back to a Heimlich maneuver or even a manual extraction of the offending agent with a finger. The latter, however, can potentially make things worse by further pushing whatever is causing the blockage deeper into the larynx, cutting off the small amount of air that is getting through.
Sometimes anesthesiologists use a special type of curved grasper called a Magill Forceps4 to pluck an object from the back of the throat after using another instrument called a laryngoscope,5 a lighted retractor that holds down the tongue, thus allowing us an unobstructed view of the larynx and vocal cords. We use laryngoscopes to “intubate” patients – that is, passing a tube through the vocal cords into the trachea to establish a secure channel through which we deliver oxygen and anesthetic gases.
As the elevator doors open, I see the huddle of doctors and nurses surrounding the crib of this small child being manually ventilated with oxygen, a clear plastic mask covering his mouth and nose. I can hear the awful high-pitched squeal and wheeze of the oxygen escaping around the edges of the mask rather than being delivered to the lungs. I am afraid that this will not be one of those quick and lucky situations.
The child is decidedly blue, pale around the mouth and eyes. His small, fragile body is slack, without muscle tone. We rush into the operating room and place him on the table. The anesthesia tech quickly transfers the cables from the transport monitor to my machine. Then, I take over the task of attempting ventilation.
I look up at the monitor that measures the percent oxygen saturation of circulating hemoglobin, the molecule that carries oxygen so efficiently to the rest of the body. I see a number alarmingly in the low twenties. It should be in the high nineties.
The lower the number, the lower the pitch the machine makes with each beat of the heart. This pitch portends doom. The heart rate is also steadily decreasing, an ominous sign that this child is about to have a full cardiac arrest.
I inject atropine and then epinephrine into the IV already established by a skilled EMT on the way to the hospital. Then, I quickly look inside his mouth and throat with my laryngoscope and see nothing but mucus and blood. It appears that someone had looked before and stirred up a mess.
As the oximeter’s pitch drops even lower, I tell the nurse to begin chest compressions. And, I ask the surgeon to prepare to cut the neck to try and establish a surgical airway. This is difficult when the patient is an adult, but it is much harder when it is a small child. I force myself to breathe slowly and stop my hands from shaking.
As a desperate last effort, I decided to take one more quick look inside the pharynx with my laryngoscope. This time I see something different. There’s a small glint, silver and shiny, reflected in the bright fiber-optic light from the tip of my laryngoscope blade. It is the thinnest visible edge of a dime.
The rest of it is buried in the swollen tissue, mucus, and blood obstructing the vocal
cords. It is wedged tightly by its serrated edge. I can understand why the paramedics and maybe the ER doctor missed it. Taking the pediatric Magill forceps in my free right hand, I fix my gaze on the tiny crescent moon of the edge of the dime. I don’t want to lose sight of it.
Above the background noise, I hear the pulse oximeter’s tone bottoming out, past the point where the numbers are even accurate. The child is purple and mottled. A full arrest is seconds away.
I’ve stopped shaking, and my hands are surprisingly steady. I aim for the small, barely perceptible glint and feel the solid metal between the jaws of the forceps. Gently and carefully, I pull it out. A rush of stale air follows.
The small coin had acted as a one-way valve, trapping the depleted air behind it. Now that it is gone, I can freely ventilate the lungs with pure oxygen.
After an agonizing number of seconds, I hear the oximeter’s pulse and pitch recover along with the oxygen saturation. The pallid limp child finally and mercifully becomes pink with life-giving, fully oxygenated blood. He begins to cry.
To this day, even awake, I cannot think about this case without feeling the familiar tightness in my chest, as well as a stomach-dropping sense of dread. Even though I know that this child made a miraculous full and symptom-free recovery, and even though I have had the opposite experience of having patients die in the operating room who were critically ill or traumatically injured and not expected to make it, this was the closest I have ever come to losing someone… a child, like this.
Working as we do in this environment, at the edge of the precipice, one never knows if the next elevator will be the one that opens to replay the nightmare over again.
My children are grown up now and no longer live with me. But, when they were younger and still in the safe embrace of my old house in their bedrooms down the hall, I couldn’t help myself. I would awaken, startled from my restless dreams in the deep hours of the night, sit up and listen intently, staring into the dark.
I’d swing my stiff legs out of bed and walk as quietly as I could down the hall to my daughter’s room. Pausing, I stand at her door for a moment, hovering, watching her uncertainly. Then softly, I go to sit on her bed and gently cup my hand near her mouth, reassured. Slowly, deliberately, I would count each warm breath as I stroked her precious face. One…two…three…four…
Other stories by this author:
An Anesthesiologist Learns the ‘Facts” about Epidurals in Childbirth Class
Perchance to Dream: A Suicidal Teen Shapes a Doctor’s Perception of Despair
***
Performing the Heimlich Maneuver on a Child or Infant, YouTube Video – httpss://www.youtube.com/watch?v=aXaLc-AwX2g
Dr. Swisher captures exactly the rapid transition from calm to terror that happens when even the most highly trained and experienced doctor is faced with a dire emergency, such as a pediatric airway emergency, that requires immediate intervention. I know because that was my life too when I practiced emergency medicine at a very busy ER in San Francisco.
One minute I could be joking with the nurses while moving from one routine case to another. Colds, flu, lacerations, sprains, infections…all things that could be dealt with without breaking into a sweat.
But the sudden arrival of a toddler in acute distress and my heart would race and my breathing quicken – just like it’s described in this story. In fact, when I first read this story, my pulse got fast, and I experienced a sense of foreboding. It was like being in the ER again. For those of you who haven’t had this experience, I can promise that this kind of work is exciting and rewarding. It is also the stuff of nightmares.
Like many kids of the boomer TV generation of the nineteen-sixties, my first exposure to the great works of western civilization was by watching Bugs Bunny cartoons. Who hasn’t enjoyed the classics interpreted by Looney Tunes? Whether it was first hearing Rossini’s Barber of Seville, or Bizet’s Carmen, we relied on cartoon characters to be our cultural guides.
I remember one cartoon where Daffy Duck played Hamlet in the iconic “To be or not to be” scene, followed by Elmer Fudd’s answering shotgun blast. When the smoke cleared, Daffy’s face was blackened, his frilly collar was opened like burst barrel staves. His bill was blown backward. It was hilarious! “Shoot the Duck! Shoot the Duck!” Cartoon violence and an education! We had it good.
New Dr. Margaret Cary‘s Review Notes appear at the end of the story.
Of course, when I was confronted with the consequences of a real-life shotgun injury as an anesthesia resident on the trauma ICU rotation at Seattle’s Harborview Hospital, it wasn’t so funny. A teenager in some particularly dark moment in his young life had decided to just end it.
He managed to position the barrel of the gun so that it aimed just under his chin, the cold steel pushing into the soft skin below the mandible. I imagined he used his toes to pull the trigger. Or he had it rigged somehow that he could fire it with a stick.
Needless to say, he must have given it some thought – but clearly not enough. When it fired, the shotgun kicked. He survived the blast of buckshot that blew off his jaw, his tongue, and the entire front of his face. It left him speechless, sightless, and grotesque – but his brain and dark suicidal thoughts were intact.
I spent the better part of four weeks in a cold and wet Seattle winter on my trauma rotation rounding on that boy in the ICU and after on the ward. My job as the resident on the service was to gather and report the results of all the daily lab tests in order to track his condition. “What is his blood count today, Dr. Swisher? What is his acid-base status? Are his electrolytes normalizing?”
Related Content: Suicide in America: Understanding the What and Why
I learned about a condition known as SIADH, or “Syndrome of Inappropriate Antidiuretic Hormone” secretion, that can occur after a concussive blow to the head. Serum levels of the electrolyte sodium go out of whack. When the level gets too low it can be lethal.
So, I was a meticulous record keeper. I was diligent in following every drop of fluid and electrolyte that went into his veins and later through the feeding tube that snaked down the hole that used to be his nose, into his stomach.
I learned a great deal of physiology and medicine from taking care of him. I still remember my feelings of pride and competence after replacing an infected central line. Or when working inches away from him with surgical magnifying loupes, carefully debriding the damaged flesh that used to be his face. I did this every day for a month. To me, it was the ultimate doctor-patient relationship. It was practically intimate.
But many years later, when I think back to him lying alone in his dark, gloomy corner room in Harborview hospital in the thick of that cloudy, cold, and wet Seattle winter, unbidden and intrusive questions well up from a deep place in my mind.
Did anyone know how troubled and alone he felt in the months and days leading up to his attempt to abruptly and messily end his existence? Who were his friends? What was his childhood like? Most importantly, who was he?
At the time I had neither the maturity nor the courage to ask these questions myself. It is to my regret and shame that I don’t have a single recollection of actually talking to him about things other than what I was about to do to his body – though I must have. I would like to think I did, and hope I did, but I am not so sure.
Although he could not speak, he could hear, and certainly was capable of listening. I am most afraid that even if I did try to carry on what would have been a one-sided conversation, it wasn’t about anything important, anything relevant.
And now, over twenty years later as a father with teenage boys of my own, I have so many questions and so few answers. Why did he feel that life at sixteen was no longer worth living? Did he have any idea what his actions would do to his parents? Was there not a single person in whom he could confide? I will never know what he might have said, and it still haunts me. I try to squeeze my memory like a dry sponge for clues.
He had a mother, but I barely remember her. I never once saw his father. She was a small, pale, quiet woman who sat in a chair just inside the door to the room but far from the bed of her son, afraid to venture any closer. It was as if he had a disease that she could catch.
She hardly spoke, and when she did it was only in reply and then in brief monotone whispers. She didn’t seem sad as much as burdened and defeated. Now she was facing a cruel and uncertain future that held in its grasp a blind, mute, and faceless son. How would she care for him, and in what way? I was certainly of no immediate help, and even less use to her in the long term, so I didn’t try.
Being an emotionally helpless resident on a trauma service confronting the problems of the world is hard. But being an isolated teenage boy is much harder. I remember that time in my life all too well. Emotions are intense but lack the substance of experience. The desire to act is strong but knowing which direction to go is nearly impossible.
I have read Hamlet many times now and have it practically memorized. Like Hamlet, I abruptly lost a father and then watched helplessly as my mother hastily re-married a man I did not trust. And, whom I also knew did not trust me.
As a teenager, I was dark and moody, and like Hamlet full of unrealized thoughts of revenge. After I first read the play in Mrs. Shepard’s high school English, I was struck dumb with self-recognition! I imagined myself confronting my father’s accusatory ghost on the ramparts of my suburban Long Island home. I desperately wanted to believe my stepfather had poured poison into my father’s ear, stealing my mother.
I secretly longed for vengeance but didn’t know how to act. I also suppose like many a depressed teenager, I morbidly fantasized about taking “…arms against a sea of troubles, and by opposing, end them”. But unlike my faceless patient at Harborview, I never would have actually tried.
And so, I have become the father now, a man tempered by time and experience. I am no longer filled with rage and passion but have settled into a comfortable and safe existence.
As many a parent who lives in this privileged corner of the world, I carefully watch my sons for signs of depression. When they seem down and alone, I really try to talk to them. Sometimes I am successful at getting through. But my fear is that many times I am not and they regard my counsel as irrelevant.
I cannot be like my father, like the absent elder King Hamlet, doomed to walk the night as a pale ghost commanding his son to take up the sword against an uncertain enemy. I am all too real and disappointingly human. I think I am more like Polonius, the foolish and bombastic father of Ophelia and Laertes, dispensing dim advice and watching from behind the curtains as the world and its intrigues unfold.
***
I originally published this story on my PokitDok blog back in 2012. I have thought about it many times since, for both personal and professional reasons. This young teenager attempted to erase himself and his own life and succeeded in quite literally erasing the most prominent part of his physical identity, his face.
His attempt led undoubtedly to a markedly different world of pain and suffering for himself and his family. It is not a story with a happy ending. Truth be told, I don’t know how the story ended, or if it even did, as I lost contact with him and his family after the conclusion of my Intensive Care rotation at Harborview Hospital in Seattle. I struggle still to this day, more than thirty years later, with unwelcome but persistent thoughts of guilt over what I did not, or could not do for him and his family.
One of the problems with medical training that is seldom discussed is that young physicians are often put into emotionally difficult situations for which they are ill-equipped to handle due to their lack of maturity and experience. I often wonder how I would have comported myself differently after having the experience of a long marriage, having raised three children to adulthood, having been diagnosed with a long-term moderately debilitating medical condition of my own.
Our perspectives change as we grow older. We watch our children go from babies to toddlers, to elementary school students, absorbing the world like a sponge. They become awkward adolescents, achingly aware that the world isn’t always a kind and magical place.
They encounter peer pressure, bullying, and an intense desire to fit in and to be socially accepted. And inexorably, they drift from the comfort and security of home and family, growing more distant and inscrutable.
They pass through tempestuous teenage years, finding their own place in the world. Their personalities harden, giving the first solid glimpse of who they will become as adults. They take risks and get knocked down. Hopefully, they get up and learn from their mistakes and misadventures.
They discover attraction, attachment, sex, and love, while we as parents watch, sometimes helplessly from the sidelines.
They frequently make errors in judgment that we see telegraphed from a mile away. And, yet we can often do little to stop the occasional emotional or physical carnage.
Yet through all this, they have moments I can only describe as divinity. They amaze us with their insight, talent, and acts of becoming. Every now and then, however, some don’t make it. It seems more and more a modern affliction that younger and younger adolescents see no way out and thoughts of self-harm, and even suicide, bubble to the surface from some deep well of sadness and despair
I come from a close family, that was supportive on the one hand and demanding on the other. My sister, brother, and I were always expected to do well academically and in life.
There wasn’t a lot of talk about emotions or happiness, or lack thereof. But we were mostly happy despite the devastating loss of our father at a very young age. Despite this, or maybe because of it, we survived and prospered.
None of us, however, had depression. True depression – the kind that is seemingly impossible to emerge from. I still watch my now-adult children very carefully as my concerns for them have deepened. Their problems are no longer childhood problems but are ones that adults face. Hence they are more complex and capable of leading toward paths of greater darkness and uncertainty.
This has been a hard year for young people at the very genesis of their adult lives. Early careers and nascent dreams have been upended. Critical socialization has been put on hold. In my children’s case, a Senior Year and college graduation simply vanished like smoke, the idea and promise of it tantalizingly real, yet unfulfilled.
My daughter and her friends drifted away from each other at one of the most important times of her life. My middle son’s dreams of returning to a job in Japan, after having studied there in college, were also dashed as travel was curtailed. And my eldest son, a world away living in Australia cannot visit home and we cannot visit him.
These problems, I realize, are not unique to me, and I am so thankful we are all healthy and have been spared the greater tragedies of COVID. However, there is a sadness I sense in all of us. So, again, feeling more like Polonius or Prufrock, I wait expectantly, but cautiously to see what the next year brings. I hope that equal measures of joy and fulfillment are waiting for all of us around the bend.
“Dr. Swisher’s powerful essay illustrates the profound impact our patients have on our lives, particularly early in our careers. I have been teaching narrative medicine to medical students at Georgetown Medical School for a number of years.
The young doctors-to-be in my classes often write about memorable encounters with patients. Nicole Boisvert’s “My First Patient, My First Death”, for example, describes her experience of being a medical student caring for a woman during her dying days. As is true of the young Dr. Swisher in this essay, she found she was not prepared to respond fully to her patient’s complex needs.
My love for music began when I was a toddler, mesmerized while watching a television program that featured a violinist accompanied by a symphony orchestra. As a result of this inspiration, I began playing the violin at age 5. A few years later I took up the piano.
Playing music to share emotion, love, happiness, and aid in consolation was a healthy ritual that had been passed on through my family’s generations. Most notable was my grandmother, Edith, who also played the violin.
It wasn’t until I became an adult, however, that I found a clear understanding of how music could console and help bring hope.
Like most, I have faced hardships, loss, and tragedy in my life. My first experience with loss occurred when I was just 8 years old and one of my best friends died from brain cancer. Only a year later, my Aunt was killed by a drunk driver. However, these experiences did not prepare me for one of the most impactful losses of my life.
In 1999, I was confronted with the situation of my wife struggling with clinical depression during her first year in medical school at Oregon Health Sciences University. I ultimately decided to add two years to my four-year medical school curriculum in order to be with her.
One of the years included a research year that afforded me time to participate in the Portland Columbia Symphony. Despite the added time together, my wife continued to suffer from her advancing disease and tragically passed away in 2011 during our first years of practice.
For a time, I was consumed by grief over the tremendous loss of my loving wife, missing her intense laughter and fierce interest in healing the suffering as a medical student.
I was also in grief over the loss of love and the medical expertise that she had to offer to humanity. In her final years, she held the status of a board-certified physician but was still finishing her post-graduate training and certifications in medical acupuncture and palliative care.
The healing powers of music provided me with relief and calmed any negative feelings, such as disappointment, that develop from dealing with difficult patient outcomes. I rely on musical experiences, either listening to it or creating it, to help me care for myself, my patients, their families, and my community.
But with dreams lost, there is room for new dreams to grow. Just as in music, we can hear the beauty of harmony only yielded by shades of dissonance. Music has allowed me to move beyond grief and create a more symbolic message to my community and colleagues.
Beyond grief and tragedy, music has also helped me deal with and manage the daily stresses of my career. That includes dealing with the potential of physician burnout, a growing problem in healthcare. High levels of physician burnout are considered to be an early warning sign of dysfunction in a healthcare system.[1]
Research has found that professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner. Dissatisfaction is driven by factors that impede this effort [1]. These factors include
I feel very well supported by my leadership and medical group. However, my work as a palliative care physician can sometimes be unavoidably stressful or heavy with emotional grief.
A journal review published in The Journal of the American Medical Association (JAMA) in 2010 summarized various approaches identified in research studies and randomized controlled trials including reflective writing, meditation, and vicarious post-traumatic growth.[2] I found that many of the proposed strategies involved creative sharing of emotion that could be experienced by others rather than done in a vacuum.
Certain meditative pieces on the violin have a soothing effect on me. And, I find that playing the rhythmic ragtime piano after a long day can have an uplifting effect on me.
Music provides me with personal satisfaction. It has also helped me manage stress and potential burnout. This is especially true when I share it with the community in the form of lessons for children or free concerts to the public.
Interestingly, music also helps bring me more awareness as a physician. Working in palliative care, I come across patients and families making difficult end-of-life decisions. These are sometimes adversely affected by cultural attitudes and poor access to information and planning.
We practice medicine in a culture that is heavily reliant on the biomedical model. This model can sometimes fall short of addressing the cultural and spiritual suffering that can occur at the end of life. I find it important to go beyond evidence-based research and understand the historical and cultural basis for the varied beliefs, values, and behaviors that occur when there is a threat of life or functional loss.
Music allows me to find humility and honor in being a physician during difficult times. When I share music in an open community environment like a street fair, it allows me to stand in awe of the open sharing of love and respect between diverse members of the community.
Professional societies, such as the American Medical Association (AMA), have developed resources to help physicians. The AMA wellness program is designed to help group practices improve physician job satisfaction and reduce physician burnout. The goal of the program is to benefit everyone within the organization.
I encourage every physician to take a step back and evaluate whether they could be experiencing signs of professional burnout. And then take the time to determine if there is a creative outlet for healing.
Our ability to express in the form of music, creative writing, or visual art is perhaps our best vehicle for bringing inspiration and purpose to those around us who also suffer in life.
Of course, you probably noticed that I have a passion for music. I also possess a clear understanding of the reasons to share this passion. So it should not surprise you that I believe strongly that every healthcare worker has the potential for developing a resonance between the suffering we experience and the healing in the humanity around us.
Have you been wondering how much money US doctors made in 2020? It was, after all, a year marked by one of the worst health crises in modern history – the COVID-19 pandemic. The impact on our healthcare system has been profound, including impacts on physician compensation.
Not only were hospitals inundated with extremely ill patients in certain parts of the country but their most lucrative source of income, elective surgeries, evaporated overnight.[mfn]1[/mfn] This affected everyone who works in hospitals, including surgeons, radiologists, and other hospital-based-physicians.
Furthermore, visits to primary care doctors dropped precipitously as we were confined to our homes.[mfn]2[/mfn] And, the fear of catching COVID at our doctor’s office scared the bejeezus out of many. Even oncologists and other specialists experienced patients staying away even when they urgently needed the care.[mfn]3[/mfn]
Doctors and other healthcare workers found themselves in an unexpected situation with drastic declines in income and even work furloughs.[mfn]4[/mfn]
Interestingly, but not surprisingly, the healthcare sector responded to these threats with innovations that helped turn the financial calamity around. Telemedicine was rapidly instituted.[mfn]5[/mfn] And, strict procedures were implemented to make surgeries and visits to the doctor’s office safer.[mfn]6[/mfn] Patients were reassured to see their providers wearing masks and face shields.
So, what has been the net effect of all of this on doctor’s incomes year-to-date? Let’s take a look.
Doximity is the largest professional network in the US having more than 70% of all U.S. doctors as members. They have been collecting data from survey responses from 135,000 licensed US physicians over the past six years. This is the fourth year that they have published a Physician Compensation Report.
According to one of the lead authors of the story, Peter Alperin, M.D., a practicing internist and the Vice President of Product at Doximity, this survey differs from other physician compensation reports in two important ways:
Compensation growth was only 1.5% according to this year’s report. This is quite modest compared to increases of up to 4% in previous years. Further, because the 2019 inflation rate was 2.3% (as measured by the Consumer Price Index)[mfn]7[/mfn], it suggests that physicians overall had a decline in real income.
There is more than a $100,000 difference between the metro area with the highest compensation (Milwaukee – $430,274) and the area with the lowest (San Antonio – $329,475). But it’s hard to know what this really means because there are many factors that contribute to the calculation of “average” compensation, including:
The report provides some detail on another important factor impacting compensation: employment type.
It is interesting to note that metro areas with the highest cost of living [mfn]8[/mfn] do not appear on the list of places with the highest compensation.
That speaks to the fact that there are other considerations besides compensation and the cost of living that physicians may take into account before they pack their bags and move to Milwaukee. These include:
I could go on and on, but you get the picture. Compensation is important, but it isn’ everything.
Providence, Rhode Island tops the list with an 8.9% growth rate followed by Portland, Oregon with 8.6%. Again this is hard to interpret because so many different factors contribute to how rapidly compensation increases (shortages of physicians, insurance status of patients (and more). So I will just leave it at that.
The single most important decision a medical student makes is what specialty training to pursue. You have to start applying for residencies in your 4th year. However, you may have had to arrange rotation opportunities to position yourself to get a coveted residency long before that.
There is no question that potential future earnings may play a role in some of those decisions, luring soon to be newly minted doctors into highly compensated specialties. It may also discourage some medical students from choosing the lower-paying specialties, particularly if they are staring a $100,000 or more in student loan debt.
So what did the report show about who makes how much?
Sadly, the report documented a 28% wage gap between male and female physicians. This is up from 25.2% last year. We have been arguing about why there is a wage gap ever since I got into medical school as a result of the women’s movement that swept the country in the 70s. This is what I have heard about this topic my whole career:
But this year’s increase in the wage gap may also reflect gender differences in the impact of the pandemic on the ability to continue working at the same intensity as prior to the shutdowns.
Schools closed down so daytime “childcare” evaporated. Kids were now home all day and many required help with online learning and even full-time homeschooling when online options were not adequate.
Doximity’s Dr. Alperin, says that “women are usually the ones to called upon to make the sacrifice” if one parent must stay home to care for the children. In addition, because male physicians make more money than women physicians, they may feel that it makes sense for the family unit if the higher wage earner is the one to return to work
No matter that “we have come a long way, baby”, the bulk of these duties still fall to the moms of the house – even if she has a medical degree.
In fact, the widening of the wage gap between men and women has been reported in other industry sectors as well.[mfn]9[/mfn]
The report shows that there are no medical specialties in which women physicians earned the same or more than men. So even if women enter the higher-paying specialties, they still make less than their male colleagues.
Like many other people in the US, physicians took a financial hit because of the coronavirus pandemic. However, their compensation is still quite generous, placing many of them in the Top 10%. The most troubling finding in the report is the increase in the persistent gender wage gap in physician compensation. It will be interesting to see if this returns to “normal” once the pandemic is under control and life goes back to more or less normal.
1. ITIJ, US hospitals losing around $50 billion a month due to Covid-19. May 4, 2020. https://www.itij.com/latest/news/us-hospitals-losing-around-50-billion-month-due-covid-19
2. Rubin R. COVID-19’s Crushing Effects on Medical Practices, Some of Which Might Not Survive.
3. Papautsky E, Hamlish T. Patient-reported treatment delays in breast cancer care during the COVID-19 pandemic. Breast Cancer Res Treat 2020 Nov;184(1):249-254. doi: 10.1007/s10549-020-05828-7. Epub 2020 Aug 9.
5. Salber P. Doximity’s New Telehealth Application Makes It Easy to Connect, The Doctor Weighs In, June 3, 2020. https://thedoctorweighsin.com/doximity-telehealth/
6. Salber P. Clinical Care of Cancer Patients in the Age of COVID, The Doctor Weighs In, Aug 8, 2020. https://thedoctorweighsin.com/clinical-care-cancer-patients-covid/
7. U.S. Bureau of Labor Statistics, Consumer Price Index: 2019 in review. January 16, 2020. https://www.bls.gov/opub/ted/2020/consumer-price-index-2019-in-review.htm
8. Eastman S, Vazquez-Soto A. What is the Real Value of $100 in Metropolitan Areas, Tax Foundation 2020: https://taxfoundation.org/real-value-100-metro-2019/
9. New York Times, Pandemic Will ‘Take Our Women 10 Years Back’ in the Workplace. September 26, 2020. https://www.nytimes.com/2020/09/26/world/covid-women-childcare-equality.html
Methodology: Doximity used self-reported compensation survey data from 2019. and 2020 from ~44,000 full-time, licensed U.S. physicians who practice at least 40 hours/week. Responses were mapped across metropolitan statistical areas (MSAs). For more details, please refer to Doximity’s 2020 Physician Compensation Report.
Original article published in 2015. Updated 2/2/17. Updated 11/8/20.
Women in medicine are at risk of physician burnout due to COVID-19 due to many different factors, including:
Further, they must continue to deal with all of the job-related stress that existed before the pandemic, including:
No wonder women in medicine are feeling overwhelmed and are at risk of burnout.
Since the onset of COVID-19, people worldwide have had to learn to adapt to change quickly. The problem with this, however, is that our brain doesn’t like change. It likes to predict the future and when we face change, this means one thing: uncertainty.
The pandemic has turned the world as we knew it upside-down. Things we previously took for granted, like getting together with friends or going to work, became risky.
In addition to dealing with the possibility of contracting COVID through everyday activities, medical professionals are also at increased risk of contracting the virus through the treatment of their sick patients.
Related Content:
Survey Shows Women in Medicine Still Face Inequities
Prioritizing Healthcare Workers’ Mental Health During COVID-19
While they are needed now more than ever, medical professionals are losing their jobs and experiencing a reduction in pay and hours. Those who have not yet been affected are worried about the future of their career and financial stability.
Because most schools in the United States have switched over to a digital format, much of childcare and homeschooling have fallen on parents. Traditionally, women have been the primary ones to handle work within the home [3]. Therefore, it is not a far stretch to imagine that they are also the ones who are taking on most of these domestic tasks now.
While these women might be high achievers, many say they are working hard for their families. The trouble is their career takes up so much of their time that they have less time to spend with their loved ones. Even when they have the time, they often experience emotional exhaustion, [4] that may keep them from being fully present.
Perhaps, that is why 40 percent of female physicians end up leaving or cutting back their hours by their sixth year [5]. A similar trend can be seen with female nurses whose turnover rates are purported to be as high as 38 percent [6]. However, working less can bring up additional stress related to paying back student loans and other financial debt.
For all these reasons, being a woman in medicine now more than ever can feel like being in survival mode. Indeed, when demands are excessive and resources are short, this is a recipe for burnout [7].
As it turns out, 42 percent of physicians reported being burned out according to a recent online survey [8]. A similar trend can be seen with nurses who normally experience emotional pressures in their jobs which, during a pandemic, can lead to stress and burnout [9].
When these professionals are not at their best, they suffer a decrease in energy, morale, and job performance. And, the quality of their medical care goes down.
The effect of this trickles down to patients who receive poorer quality care. And they may suffer higher rates of infections and increased mortality rates due to medical errors [10].
Some women in medicine may turn to junk food or overindulge in drugs or alcohol to cope with stress. Such maladaptive coping translates into weight gain, poorer health, and addictions. All of these things have further consequences that negatively affect sleep, mood, and relationships.
While the external stressors they face are real, it is up to the individual to learn to manage their thinking to avoid feeling anxious, overwhelmed or burned out. This is possible even during COVID-19.
In addition to environmental stressors, part of the reason why anxiety and burnout are an epidemic among healthcare workers is because of the stigma around mental health in the field of medicine.
There is an expectation that healthcare providers are superhuman. And, that they can manage to deal with emotionally draining and sometimes traumatic experiences while navigating challenging work-related conditions without being affected. This is clearly unrealistic and very damaging to their long-term well-being.
Nevertheless, not all hope is lost. The key to staying afloat amid the chaos is self-management. It may seem that the reasons for the stress are external factors and therefore beyond your control. However, our response to stress is a product of our minds.
Think of a time when you were in the same situation as someone else. While you may have been negatively affected by the circumstances at the time, your friend or colleague was unphased.
The reason for this difference in outcomes relates to perception. It is not what happens to us that makes us feel how we do. Rather, it is how we think about what happens to us that leads to those feelings.
When we misunderstand someone’s intention, we can feel upset by our interpretation. Once we realize what they truly meant, our perception shifts. Consequently, so do our feelings.
The same is true in the workplace. It is your thinking that creates your current emotional state, not the circumstances. When you shift your mindset, you shift your anxiety into a state of calm.
The next time you find yourself ruminating about mistakes you’ve made or worrying about the future, bring yourself back to the present moment. Recognize that you have a choice about where you focus your mind.
The world around you will remain imperfect. The healthcare system in which you work will continue to be deeply flawed.
When you fixate on what should be different, you’ll only feel frustrated. Instead, focus inward on what you can control. This is because the only thing you have control over is yourself.
By learning to manage your thinking, you can make positive changes, such as:
The responsibility of self-management and self-care may seem like an added burden to your already burdened life. However, by increasing Emotional Intelligence and managing your energy, you lighten your load.
What may have seemed overwhelming previously may feel easier when your perspective shifts, when you are in a state of balance, and when you are able to accept aspects that exist outside your control.
You are stronger than you realize and no matter what, remember—you always have a choice.
During the COVID-19 pandemic, women in medicine have been faced with heightened demands and lower than normal resources. This combination can overwhelm and bring about anxiety and burnout.
By focusing internally rather than externally, you can regain control over your reactions and refocus on what really matters long-term.
Decades ago, choices for a career in medicine were limited to small private practice or large academic, primarily research, settings. So, physicians in training could focus on acquiring vast amounts of clinical knowledge as well as technical skills.
If they wanted to go into research, there was always the option of choosing an MD-PhD path. If a career in public health was the goal, it was highly recommended to get an MD-MPH.
The advent of managed care in the 80s opened up a slew of new career opportunities on the business side of medicine. Suddenly, doctors could be health plan medical directors, experts in utilization management, or Chief Medical Officers. They could run large practice groups or even run hospitals.
Soon after the managed care revolution, the country went through serial efforts to reform our increasingly dysfunctional healthcare system (remember the Clinton plan?). This opened up opportunities for careers in health policy and health services research.
Later, the explosion of digital health teed up entrepreneurial opportunities unimaginable to prior generations of physicians. Now, docs could start companies, fund companies, or become advisors to start-ups.
This was so enticing that a number of young doctors I met in the health tech field decided not to complete their training. They told me they felt they could help many more people by developing and deploying their innovative health technology solutions.
The current pandemic has opened up a new possibility – becoming a medical pundit on cable news. We have had medical experts talking to us from TV for a long time (think Sanjay Gupta), but the number of MDs who get this gig has been small compared to what is going on now.
Of course, many of these docs don’t get paid for their appearances. However, some of them may be able to parlay their experiences into a full or part-time job.
So, it is an exciting time for physicians, but it is also a confusing time. How can doctors prepare themselves both for the present and the future? What types of skills, beyond clinical, should they be acquiring? When should they acquire them? And, how?
I like to answer these questions by reminding people that careers last a lifetime. You don’t have to do everything all at once. And, you don’t have to do anything forever. You can take left turns. And, you can reinvent yourself.
You can do this in a planned or in an opportunistic way. I know alot about the latter because that was the serendipitous and convoluted path that I have followed.
I trained in academic endocrinology at the University of California San Francisco, working with some of the giants in the field (Peter Forsham, John Karam, Claude Arnaud). At the same time, I was moonlighting in the ER at Kaiser Permanente in San Francisco to bring in some extra cash.
It was the early days of emergency medicine. There was not even a residency in San Francisco at the time. So by day, I was working up complex endocrinology cases. But at night, I was intubating asthmatics and treating desperately ill patients in heart failure.
One day, after getting back ambiguous results after a year-long workup for a rare endocrine tumor, a giant light bulb went off in my head. Emergency medicine thrilled me, endocrinology did not.
So I left UCSF and became a Permanente Medical Group emergency physician, a position I held for the next 15 years. I also got involved in my specialty society, eventually becoming the first woman President of the American College of Emergency Physicians in California.
This opened up a chance for me to do a 2-year Pew Fellowship in Health Policy at UCSF’s Institute for Health Policy Studies under Phil Lee who went on to serve as Undersecretary of Health in the Clinton administration.
Once again, these experiences led to an opportunity to leave clinical practice and start a new career as a Physician Executive for the national Kaiser Permanente organization. I was the first director of National Accounts. In that role, I helped sell the health plans to large employer groups by talking about our clinicians and clinical programs.
That position led me to yet another position – one that was quite unique. General Motors was struggling with the cost and quality of their health plans. They worked with Kaiser to bring on a team of people to help them with their managed care strategy. I was the doctor of the group and the team lead.
I spent the next six years as an executive on loan to General Motors. Along the way, I picked up a healthcare-focused MBA from the University of California Irvine.
I made two attempts to start companies, but, in retrospect, I have discovered, sadly, I am missing a key ingredient of a successful entrepreneur—sticking with it at all costs.
In between my attempts to build a company, I moved in and out of healthcare consulting, probably the most lucrative and educational of all of my endeavors. I also had several different positions with different health plans, including serving as Chief Medical Officer of a Medicare Advantage plan in Houston.
In 2006, in the early days of blogging, I created The Doctor Weighs In. I have have been running it ever since. It has morphed from a diet and weight loss blog to what it is now – a multi-authored health news site. I, now, consider myself a full-time health journalist.
I tell you all of this not to puff myself up because you are probably thinking I am a flake or at least a bit crazy. Rather, I tell you this to emphasize that the opportunities for physicians to make contributions to healthcare are endless and ever-changing. You just have to be willing to try new things. It is a very exciting time to be a physician.
I have had some intense discussions with medical students, residents, and early career doctors about whether they should complete their training. However, I still believe that a strong foundation in clinical medicine is part of what differentiates doctors from others who go into the business of medicine.
Yeah, the internship is a drag. And you may be chafing at the bit to get started in real life. But I have found that really knowing medicine has been a cornerstone for my career.
At least get the MD, a license, and practice a bit even if it is in an urgent care center or a retail clinic. It is simply invaluable to have the experience of actually taking care of patients.
If you think you would like to work on the business side of medicine—for a health plan, medical group, or hospital, you need to know these two things:
That means formal or informal training in health policy and specific knowledge of the financial aspects of the type of organization you want to work in. Consider getting an MBA, but be sure you find a program that focuses on healthcare and offers some hands-on experience with the industry. Internships, if you can find them, are invaluable.
If public health is your thing, the club card is an MPH. Be sure to find a program that can give you real-life experiences and provide you opportunities to network with people who can help you get a job.
Join the American Public Health Association and go to their meetings. Volunteer with a non-profit doing public health advocacy work—these organizations would be thrilled to have a physician working with them.
If your dream is starting the next big thing in digital health, move to Silicon Valley (just kidding). Healthcare entrepreneurship opportunities are available all over the country. Volunteer to help a start-up, join an incubator, participate in Hackathons, and hang out with the people who are doing the work.
If you dream of being a real TV doctor, invest in getting a PR agent who specializes in getting doctors on various news shows. Take some classes and practice the needed skills. I actually had to take lessons on how to control my blinking!
Foundational to whatever career path you choose is developing leadership skills. The types of leadership skills that will propel you forward in business, public health, or in the media are very different from the ones that make you successful in the OR. Take classes, read books, or better yet, find yourself a good leadership coach.
Related Content: Can Professionalism Bring Joy Back to Medicine?
No matter what stage of your career you are at, it is never too late to learn new things, take on new challenges, and acquire new skills. Healthcare is a huge and growing part of the global economy. Doctors bring unique skills into the field.
You can have a very long and exciting career in medicine if you couple an insatiable desire to learn new skills with a fearlessness to walk away from the same old, same old.
Even if you don’t get tenure, a gigantic 401K, or a cushy pension, you will have had a very wild ride. And I promise that you will still be in love with medicine at the end of it.
I had the pleasure of being interviewed by Taylor Brana, founder of The Happy Doc on a similar topic. The Happy Doc is a platform that provides “inspiration, knowledge, and tools to enhance creativity, joy, and success in the field of healthcare.” Here is a link to the site and the podcast.
This story was written for LinkedIn in 2017. It has been updated for republication on August 28, 2020.
Healthcare workers around the country say they are being told not to bring and wear their own personal protective equipment (PPE) in the hospital because it might make people who don’t have it feel bad or even panic. Some are even being told that they will be fired if they wear their own masks. They are also told not to share stories about the dire conditions publicly.
These are people who risk their lives to be there for us. They are working in battlefield conditions. They are terrified not only of getting the deadly disease but also of unknowingly passing it on to their patients or their families.
They don’t have the PPE that they need to keep themselves safe so they are wearing the same gear all day long. And then, they reuse it on the next shift and the next.
Here’s a sampling of their stories:
The American College of Emergency Physicians responds
Finally, I just received a press release from the American College of Emergency Physicians expressing outrage over hospitals retaliating against frontline health workers who are speaking out about the lack of personal protective equipment (PPE). It is worth reading the entire statement. I have highlighted key points:
“The American College of Emergency Physicians (ACEP) is shocked and outraged by the growing reports of employers retaliating against frontline health workers who are trying to ensure they and their colleagues are protected while caring for patients in this pandemic—including an emergency physician in Washington State who was recently terminated after he spoke out about his hospital’s lack of personal protective equipment (PPE).”
William Jaquis, MD, FACEP, president of ACEP, said: “Emergency physicians are prepared to handle virtually anything thrown at us as we seek to treat and heal our patients, however, we should not be forced to put our own lives at risk and have our jobs threatened simply for wearing our own supplied protective equipment.”
The growing outbreaks of the novel coronavirus, COVID-19, have already begun to strain our nation’s emergency departments causing a severe shortage of protective gear for emergency physicians and millions of other frontline health care workers. This dearth of hospital-supplied PPE, like N95 masks and face shields, has led to some buying their own or using donated equipment.”
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“Efforts to silence, penalize or unjustly terminate health workers simply for wearing their own makeshift PPE can have catastrophic consequences for trusted institutions, their staff and the communities they serve. Not only does this type of retribution remove healthy physicians from the frontlines, it encourages others to work in unsafe conditions, increasing their likelihood of getting sick.
“As we combat this pandemic, emergency physicians and other health care workers on the front lines must be appropriately armored for the battle ahead. We need every qualified physician and health care provider we have available and healthy. We are in unchartered waters, and health care workers are doing the best they can to protect ourselves and our communities. Now is not the time to be blindly adhering to outdated or irrelevant policies—lives are on the line,” said Dr. Jaquis.
ACEP will continue to fight for its members and stand in full force behind its statements on PPE and physician protections. PPE guidelines from the Centers for Disease Control and Prevention (CDC) continue to change as conditions evolve. While they should be followed, these guidelines should be considered the bare minimum for allowable protective gear. ACEP is calling on the Trump Administration to use its authority to allow emergency workers to wear their own personal protective equipment (PPE), especially when protection is otherwise unavailable from the hospital.
Each day thousands of emergency physicians work under unthinkable conditions as they bravely battle the public health crisis of our lifetime. We must do everything we can to protect those on the frontline and ensure they have the resources and support they need.”
This sad news is what those who are speaking out are trying to prevent (from a Press Release on April 1, 2020)
“About learning of the passing of an emergency physician from East Orange General Hospital in New Jersey due to symptoms consistent with the novel coronavirus (COVID-19), William Jaquis, MD, FACEP, president of the American College of Emergency Physicians (ACEP) released the following statement:
We are deeply saddened to learn that a former ACEP member and our current colleague on the frontlines—an emergency physician—has lost his fight against this virus. Emergency physicians understand that sometimes in our efforts to save your life, we may end up sacrificing our own. This is not a decision made lightly or a post abandoned in times of need. We know the risks of the job we signed up for, but we are on the frontlines in this historic war against COVID-19 with insufficient protection.
There are dire shortages of personal protective equipment (PPE) in emergency departments across the country, and despite efforts to ramp up production, we do not see significant relief in the near future. America can’t afford for more emergency physicians and other frontline health care providers to get sick or worse due to PPE shortages.
In times of loss, emergency physicians take what’s called ‘the pause,’ a moment shared between health professionals meant to halt the fast pace of emergency medicine and provide a chance to reflect. The pause gives everyone a chance to honor the significance of the day’s work and the solemn responsibility of holding a life in your hands. This is never easy. It is especially difficult when the loss is one of your own, part of your family. Tonight, we pause and invite you to join us.
We recognize that the stress of living and working in this environment is without precedent and can be difficult to manage. This evening at 8 PM EST, while many of you are safe at home, please stand with emergency care teams and take the pause in honor of a life lost on the frontlines. And remember, you can do your part to help emergency physicians by staying home and take the appropriate steps to protect yourself and your loved ones.”
This is an outrage and it needs to stop. Copy and paste this story into a letter to the editor and send it to your local paper together with a personal comment. You don’t want this to happen in your community. And, this should not be happening in our country. Never. Ever.
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30 years ago, 86% of Americans identified as Caucasian. Today that number is 64% and by 2050 is expected to be 46%.
By 2050 the Census Bureau estimates that there will be no single racial/ethnic group that makes up the majority of the American population.
As a country, we’re not ready for these inevitable changes. As an industry, healthcare is headed for a potential 2050 disaster.
A recent AHRQ study finds that across 20 access-to-care measures, Hispanics (who will be 30% of the population in 2050) reported worse care than Caucasians for 75% of the measures. African Americans reported worse care than Caucasians for 50% of measures. While the Hispanic population hovers around 18% nationally (40% in California and 39% in Texas), and is predicted to grow significantly, only 5% of practicing physicians today identify as Latino. Even fewer– just 3.8% (as compared to the 13% of the total population) identify as African American.
A CDC study estimated that if African Americans had the same adjusted rates of preventable hospitalizations as their Caucasian counterparts, there would have been almost a half-million fewer hospitalizations between 2004-2007.
A groundbreaking study commissioned by C-Change estimated the cost of cancer disparities to be just under $200 billion annually. African American women are twice as likely to die from cervical cancer (an easily detectable, highly treatable cancer) than Caucasian women.
We know from people who have studied healthcare and health outcomes just how important it is for a patient to be treated by a doctor they can understand–and who understands them.
We also know that the healthcare system as we know it today is heavily oriented toward Caucasian English speakers. This is a problem when we have an increasing number of multicultural patients particularly in Medicaid where they make up 60% of national Medicaid enrollment.
There is a growing mismatch between the needs of Medicaid patients and the healthcare system seeking to serve them. This results in poor health outcomes for patients and a higher cost for payers.
Properly deployed, technology and data can improve engagement with multicultural patients, resulting in increased quality scores and improved health outcomes. Combined with a true cultural lens, technology can be a tool that actually reduces barriers to care for patients.
Simply translating messages from English to other languages isn’t enough (at my company we call this “multicultural patient engagement 1.0”).
We need to engage patients in a way that speaks to them and says, “We understand you. We get what you’re going through. And we can help.”
A translation isn’t going to do that, no matter how much technology you throw behind it.
Language isn’t enough to tell you if there’s widespread food insecurity where your patients live. It’s not enough to tell you whether something as simple as a routine blood draw for a cholesterol screening is against a patient’s religious beliefs.
Language isn’t going to tell you that your patient is living in a building with a terrible mold problem and that’s why your asthmatic patient has been to the E.D. three times this month.
But culture can. That’s where multicultural patient engagement comes in.
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The Cambridge Dictionary defines culture as,
“The way of life of a particular people, especially as shown in their ordinary behavior and habits, their attitudes toward each other, and their moral and religious beliefs.”
When you get to know a patient’s culture, you get to know them. And once you know your patients, then you start to understand how to reach them. Then you can create content in the languages your patients speak, and you’ll have an engagement that speaks to them.
Data also plays a big role in getting to know your patients and their culture. Too often we in healthcare look at patients as a collection of data points. We try to solve each of their problems as an isolated problem that is unrelated to all of the other data points. We ignore the “unsafe neighborhood” data point and, instead, try to solve the “sedentary diabetic” data point.
But that’s not the way people work. Culture takes all of those data points and creates a holistic picture of who that patient is, how they’re likely to react/act, and what will move them. Technology can then come into play in bringing all of these cultural understandings and the relevant engagement to scale.
The best approach to scaling a solution is both large and small. “Large,” because the same technology can be used to engage millions of patients. “Small” because it is best utilized in the hands of local community physicians whose practices can range from a few hundred to thousands of patients.
Why are doctors the best choice over health plans or healthcare systems? Because patients trust their doctors. One study found that while 60% of patients trust their doctors to make the right decisions about their health, 24% of patients also rated their insurance plan as having a “low/poor” reputation.
While doctors are the best choice to engage patients, they’re also stretched thin. 70% of doctors still practice in groups smaller than 30. 55% of doctors report symptoms of burnout. But even with these challenges, there’s still a desire to do more.
The biggest obstacle actually isn’t bandwidth or burnout, it’s cost. In fact, 65% of doctors report that the biggest roadblock to increasing their efforts of patient engagement is cost. With the right strategy and mindset, this is an opportunity for payers to step in and provide resources that will help doctors engage patients better.
When doctors engage patients better, both doctors and payers win.
It may seem like a daunting task to fundamentally re-shape a patient engagement strategy. This is especially true for organizations who serve millions of patients across hundreds of communities and dozens of states. But it’s actually not. In fact, it’s only a four-step process:
It may not seem like a lot, but re-centering healthcare strategy to focus on patients and strengthening the patient-doctor relationship could be the difference between a 2050 disaster and a 2050 triumph.
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First published August 30, 2018, this post has been reviewed and updated for republication.
Medical careers require dedication, a competent attitude, and a lifestyle fashioned around long hours and overnight shifts. The latter can cause both physical and emotional stress. Most healthcare professionals can regularly be found running to their next emergency, managing a busy ward, or tirelessly overseeing bustling outpatient and waiting areas. With today’s fast food options and easy access to processed foods, developing a healthy eating routine can be difficult even in the best of circumstances. For healthcare providers like doctors and nurses, it can seem nearly impossible.
However, with these healthy eating tips and tricks, you can stay on track with your diet and manage your nutrition for a healthy, happy work week at the hospital.
Downtime in the healthcare field is hard to come by and even harder to enjoy. Doctors and nurses don’t often receive long meal breaks, if at all. And, they are understandably exhausted from long shifts. Most healthcare providers work inconsistent schedules, alternating day and night shifts. This disrupts the circadian rhythm, which can cause headaches, gastrointestinal issues, fatigue, and other problems.
Photo source: Shutterstock
Because mealtimes are often irregular, busy schedules can lead to snacking on quick processed foods like chips or unhealthy fast foods. Consuming these high-calorie low-nutrition meals can lead to a bevy of health issues down the road, including weight gain, fatigue, and heart health issues.
Irregular schedules also lead to missed meals. When we skip meals, our blood glucose levels drop. Skipping meals can cause tiredness, irritability and force the body to convert energy from less efficient sources. This equates to difficulty in thinking clearly and dizziness, which can impair performance and working ability. Skipping meals also leads to overeating when you do finally find time for a meal.
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Staying hydrated is an essential part of overall nutrition for everyone, but, for individuals with high-intensity work shifts, it is even more critical. Keeping your body hydrated helps to decrease the likelihood of headaches and diminish fatigue, as well as improve digestion, circulation, and body temperature.
Drinking water also helps us to feel fuller for longer, which means you are less likely to reach for snacks when you are well-hydrated. Always aim for the recommended eight 8-oz. glasses of water every day. You can easily monitor your water intake by packing a reusable water bottle for work.
Pro Tip: Add slices of cucumber, lemon, mint, or other fruits and berries to your water bottle to infuse it with a refreshing taste.
Many of us fall into the trap of reaching for sugary and caffeinated drinks when we need a boost of energy to get through a long shift, but caffeine might be sabotaging your efforts. While coffee is a natural stimulant that will increase your alertness and ability to concentrate in the short term, it also has long-term addictive qualities that can lead to caffeine dependency, nervousness, restlessness, muscle tremors, increased heart rate, upset stomach, and even insomnia.
Caffeine addiction is a vicious circle: The more tired you are, the more you drink, and the more you drink, the more incapable you become of getting a good night’s sleep and the more reliant you become on the effects of caffeine. As an alternative, reach for water instead. Or, if you are partial to the taste of coffee and tea, insist on the decaffeinated varieties. Green tea is an excellent option because it is low in caffeine and contains an amino acid called theanine which is said to improve mental alertness.
Pro Tip: If you do continue to consume caffeinated drinks, try to limit them to the first half of your shift, so the effects of the caffeine wear off before you go home and sleep.
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No matter what shifts you are working, make sure to maintain a regular eating schedule. Even if your “morning” is at 3 p.m. when you wake up, make sure to have “breakfast” and base the timing of your following meals and snacks off this first meal. Aim to eat your meals every four to five hours with small snacks in between.
Pro Tip: Remember, eating regular, small amounts of food is better for maintaining a healthy weight then eating one large meal to get all of your nutrition and calories, as this often leads to overeating and weight gain.
When we think of the word “diet,” we conjure up images of people unhappily restricting themselves to small amounts of tasteless and unenjoyable foods. What “diet” really refers to is our pattern of food consumption.
Eating a healthy diet does not mean you restrict yourself entirely. Instead, you seek to maintain a balanced eating routine that includes items from all the basic food groups to ensure your body is getting the daily nutrients it requires.
Doing so is rare when your food sources are limited to take-away and the hospital vending machine. Eating healthfully does not mean eating bland foods; it means you make informed (but still delicious!) choices when it comes to your foods. Make sure meal times include some form of protein like eggs, grilled chicken, beef, or Greek yogurt. Vegetarians should look for sources of protein from the vegetable kingdom, such as tofu or nuts or the many new plant-based products, such as Beyond Meat coming to supermarkets these days. Protein helps you to feel fuller for longer and provides the body with much-needed energy during busy shifts.
Vegetables and greens provide essential vitamins and minerals that enable the immune system and metabolism to function correctly and prevent deficiencies, such as anemia. At each meal, aim to have vegetables taking up at least one half of your plate, with the other half divided between protein and carbohydrate sources. You can easily ensure your nutrition is en pointe by taking the time on your off days to meal prep for the week.
Pro Tip: For healthy snacks between meals, pack protein-heavy items such as nuts, healthy protein bars (check the label for calories and sugar), and yogurts that will make you feel full and provide much-needed energy. But remember, snacks cannot and should not replace full meals.
Developing a healthy eating routine takes a little bit of preparation and dedication. With a little bit of will power and commitment to your new healthy lifestyle, you’ll notice you feel more energized and capable, and that your favorite pair of scrubs fit a little bit better than they used to. Use these essential nutrition tips and tricks to take charge of your nutrition and invest in a healthier, stronger you today.
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Once upon a time finding the right candidate for an open position in healthcare meant placing an ad in a newspaper or medical journal. It involved paper applications and in-person interviews. Credential and reference checks were done by mail or telephone. It was a time-consuming and expensive process.
Luckily, that has all changed. Healthcare recruiting, is now largely driven by technology. That’s good because it is critically important for organizations to build strong healthcare teams and hire outstanding healthcare professionals. Recruiting professionals must be skilled in HR basics but also have a high level of engagement, emotional intelligence, and other soft skills. Because of this, it is imperative that hiring personnel are well-versed in technology-based recruiting tools that are designed to help them succeed in the digital age.
Healthcare staffing shortages can be critical to the success of any healthcare system. It doesn’t matter if you work at a large academic institution with thousands of employees or a critical access hospital. Not having enough doctors, nurses, respiratory therapists, or patient care assistants can be devastating.
The importance of recruiting in healthcare goes far beyond filling staff vacancies. As experts predict that the physician shortage will peak at around 122,000 physicians by 2032. More institutions are looking to fill their openings, often strategizing innovative ways to retain staff members into the future.
Physicians aren’t the only ones short in numbers. Nursing has been experiencing a shortage for several years. And is projected to peak by 2030 as more baby boomers enter retirement. Experts and lawmakers have turned to advanced practice nurses to fill the physician shortage. But with the current state of affairs, nursing is struggling to recruit and retain skilled employees.
You may feel that effective recruiting is paramount due to the lack of qualified applicants or the dire consequences of having open positions. However, it’s clear that healthcare institutions must look to cutting-edge technology when finding new clinical and technical staff members. This also means that candidates need to have a good understanding of how these recruiting practices can impact their ability to get hired.
For human resources (HR) and other recruitment professionals, cloud computing has become a way of life for finding top healthcare professionals. Some of the best medical facilities are using cloud technology to access data on demand without the need for on-site storage. This means they can access applicant information anytime and from anywhere.
Not only do human resource departments take their operations to the cloud to store information about candidates, but they can also post positions from one portal that can touch multiple platforms to reach both active and passive talent pools. This increases the likelihood of finding the right person for the job.
This is true even if that professional is not actively searching for a new position at the time. Therefore, if a recruiter contacts you via LinkedIn or another platform, you might want to respond and learn what the opportunity is all about. Your skills may be a good fit for the job they’re trying to fill.
Creating a well-written job description is the first step in recruiting and hiring the right healthcare professional for the job. HR departments outline the scope of work in detail so that the applicant knows whether or not they can fulfill the role duties and responsibilities. Technology can help to create engaging descriptions of open positions whether they are for front-line clinicians, support staff, executive level management, or healthcare consultants.
Some tech platforms can even analyze job descriptions to find a potentially biased language. It can then suggest alternatives to the recruiters. Other platforms might work with job postings to optimize the job description and the career pages for search engines. Once the recruiter uploads the information to the platform, it can provide a list of possible keywords so that job seekers can know if they’re a qualified applicant.
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It seems everyone is active on multiple social media channels these days. If you’re looking for a new position and you’re coming up empty-handed, consider searching social media sites for employer pages. This is an excellent method employed by large and small healthcare facilities who want to use social media to recruit and hire. Look for videos of current staff sharing testimonials about their job and the company culture. You might also be able to find the name of the HR staff or recruiter so that you can contact them directly to find out what positions they have open.
Artificial intelligence (AI) is used in healthcare to treat patients. However, recruiters and human resources staff have also turned to AI to improve candidate sourcing. Instead of spending hours manually screening resumes and searching for new platforms, the HR team can find a large applicant pool in no time, especially for high-volume positions.
Some tech tools can even predict if candidates will fit into the company culture by using analytics and machine learning techniques to project your success in their workforce. The use of AI means that the HR staff spends less time search through profiles and resumes. But it also means a better hiring experience. AI can decrease the number of days it takes to fill a position. And it gives the hiring team more time in the day to build relationships with qualified candidates.
Once a job seeker has been identified as a qualified candidate, they have to start the tedious and anxiety-inducing task of interviewing. This might mean scheduling and rescheduling appointments, traveling to the potential employer, and multiple hours in face-to-face interviews.
However, technology can automate your interview scheduling and allow you to choose the best time slot from the beginning. Job seekers might also be invited to use digital video technology to conduct the interview when it’s most convenient for them. This technology uses a set of pre-arranged questions while recording the video on a cloud-based application. The HR staff and other hiring team members can review your video when they have time and get back to you with the next steps.
If you’re not located in the same state or country as your potential employer, you may also be asked to conduct an interview over a live video platform. This speeds up the process and minimizes the cost and time spent flying you to the facility until both you and the hiring managers know that you might be the best fit for the job.
Filling vacant roles from the top of the healthcare staffing continuum to the bottom is challenging. By using cutting-edge tech, HR departments decrease dollars spent and minimize the number of days positions go unfilled. And, it might even find out if a potential top performer is a toxic employee before they’re even hired.
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