Nomadic Belongings and Nicole Meline

 

Retreat.  This is a word for my sister, someone far more mature in self compassion and peacemaking than me.  This word became part of my story in the last 5 days.  A retreat with strangers.  And my 12 year old daughter.  

Wellness.  Work life integration.  Culture.  Words I have been trumpeting to my peers, to physicians and surgeons, especially women and moms.  I have spent 5 days discovering all that I do not know about these words.  

Letting go.  Following, not leading.  Not part of my vocabulary 5 days ago.  

Dancing with the lights on during the day without alcohol.  Never, before 5 days ago.  

What is home and why did I come here, to Bozeman, Montana, to be amongst strangers to spin and practice yoga and hike in Yellowstone?  Home is my family.  But my family has not been getting my best self.  Or even my medium self.  They have been getting the leftovers.  This is upside down and backwards.  So I came here to reset myself, take a risk.  And then the cherry on top happened.  My 12 year old daughter, Lila, agreed to come with me.  

We met, we practiced yoga, we did burpees, we did jumping jacks…  then Nicole asked us to share what and where our home is,..  The strong woman to my right answered that her home is sweat.  This is real for me, too.  I am an anaerobic junkie.  I don’t think I deserve to eat until I sweat.  My temper is short until I sweat.  I look different tin the mirror after I sweat.  I am a better doctor after I sweat.  I need to sweat to be a good mom, a nice wife, and kind to myself.  So a retreat without sweat would be torture.  A retreat ABOUT sweat…  one word.  YES.  

I do things for myself.  I take time for yoga 2 times per week.  I work out every day.  I get a manicure once in a while.  I read fun books.  I indulge in bad TV.  But rarely do my kids get my best self, my relaxed self.  Bringing Lila with me could have gone 2 ways. 

  1. detraction from my self care, ruining the vibe for the other women, and a bored Lila. OR
  2. everything awesome for all of us. 

We got, at least I think we got, #2 all around.  

This kid is my heart and my light, the person who made me a mom the first time.  She is smart and confident and gorgeous.  She is a dancer.  And she is warmth.  I saw this experience through 2 lenses, alternating between my own eyes and hers.  I watched her explore conversations with her new heroes and role models.  

Nicole Meline.  Never have I met someone who brings such absolute intelligence to fitness.  Emotional intelligence.  Creative intelligence.  And just plain smarts.  I sensed it when I took her classes when she was a Peloton instructor.  I feared that meeting her in real life would expose that I had projected this onto her.  But I DID NOT.  She is the real deal.  multidimensional.  Perfect and imperfect.  Strong and independent, so much so that she is ok to share humility and vulnerability and loss.  Gorgeous inside and out is a cliche, but cliches exist for a reason.  Nicole is a reason.  

After a spin class that cannot be described by my amateur writing, with so much love for movement and work, sweat and joy, strength and rhythm and music, Lila asked to buy the t-shirt she had seen Nicole wear.  She told me she would wear it to dance, so that she could remember to feel strong.  I could have gone home right then and there.  To see my daughter looking with starry eyes upon Nicole…  at her strength and joy and beauty as a successful woman, single, resilient, bringing so much to the world with her own script, this was everything to me.  

 

 

 

 

 

As if that were not enough, Lea Fulton graced us with her presence this week as well.  Yogi, dancer, a spirit of support and giving.  Lila watched Lea move her own moves.  No choreography.  And she absorbed it.  As did I.  I asked Lea to help me with a simple yoga pose, I told her I felt stuck and couldn’t get deep enough.  Instead of adjusting me and pushing me, she just said, “that looks fine.”  She took something I have struggled with for 10 years to improve and made it “fine.”  This shifted me toward ease, not an easy feat. 

The friendships…  these are women who will stay with me.  As a kid at summer camp I made friends in days that lasted a lifetime.  But not as an adult.  As a grownup friendships take years.  Except in Bozeman.  Here 5 days is enough.  

So retreat has become a word for me too.  I am full.  I am easeful.  And my daughter is here to get my best self today, and hopefully tomorrow.  Until next time, nomads.

Nope, “provider” still doesn’t work

kevinmd.com published a version of this story on Sept 12, 2018

 

In November of 2015, Dr. Suneel Dhand and William J. Carbone penned, “Physicians are not providers: An Open Letter to the AMA (American Medical Association) and medical boards.” The authors ended their piece with the following plea: “The word “provider” is a non-specific and nondescript term that confers little meaning. We, therefore, call on the American Medical Association and all state medical boards to consider discouraging and terminating the use of the word “provider.”

In Dr. Dhand’s follow up piece, he waves a white flag, as he recounts a conversation with a young resident. In this conversation, Dr. Dhand introduced himself as a patient’s “attending physician.” The resident translated this back to him by asking if Dr. Dhand was the patient’s “main provider.” Dr. Dhand writes, “Alas, the term may have already filtered through to the future generation of doctors much earlier than expected.”

Corporate influence

That future generation might be taking tips from a recent startup trend in the corporate world that aimed to get rid of titles within companies as a way to increase creativity (the idea was that eliminating hierarchy would lead to a more “open idea forum” within companies).

This concept largely failed and is slowly phasing out. In its place are companies allowing employees to develop titles that accurately reflect their training, tasks, and involvement within a team. Why? Because it’s a fact that employees are more engaged at work when their contributions are recognized.

Calling medical doctors “providers” does more than inflict eco-injury, It actually reduces morale, worth, purpose and results in already overworked doctors finding less meaning in the work that they do. A recent Pearl Meyer & Partners poll found that 92 percent of employers use job titles to define an employee’s role accurately, so why hasn’t this trend found its way into the medical world and where did it come from?

Provider origins

Where did this term originate from and why has it been widely adopted across the medical landscape? The federal definition of the word “provider” is precisely the issue with this word. By law, the term refers to “a doctor of medicine or osteopathy, podiatrist, dentist, chiropractor, clinical psychologist, optometrist, nurse practitioner, nurse-midwife or a clinical social worker who is authorized to practice by the State and performing within the scope of their practice as defined by State law, or a Christian Science practitioner.”

These are all very distinct and unique professions that range broadly from a mental health expert to a Christian Science practitioner. Some of these professions do not require any medical training at all, but the term tries (and fails) to be all-encompassing. So where did the term come from and why has it been widely adopted? The term was adopted by federal law in the early 1970s and largely left festering amidst a tangle of professions that may or may not include the abbreviation “MD” after a person’s name.

The term is insulting to other members of a medical team too. There’s nothing “mid-level” about a “mid-level provider” working long shifts and taking care of sick patients. The whole term (any way you put it) doesn’t work and needs to be changed. I know that this is not a new fight amongst medical staff, but it’s one that needs to be re-addressed and reworked. Why is anyone on a medical staff still being termed “provider” if we know that titles matter, are used to accurately reflect a person’s role within a company, and lead to better overall engagement in the workplace? It’s not only nonsensical, but it’s also detrimental.

Post Script:

If the word “provider” didn’t upset me enough before today, I am now more sure of my crusade… As a Jewish pediatric orthopaedist, I felt a full on gut punch when a woman physician shared the following with me: “In the 1937 issue of the Reichs Medizinal Kalender, a directory of doctors, the remaining Jewish doctors in Germany were stigb matized by a colon placed before their names [Figure 1]. Their medical licenses were finally revoked in 1938. They could no longer call themselves “Arzt” or “doctor.” They were degraded to the term “Behandler” or, freely translated, “provider.”” quoted from
Jewish Pediatricians in Nazi Germany: Victims of Persecution
Paul Saenger MD
Children’s Hospital at Montefior/Albert Einstein College of Medicine, Bronx, New York, USA

The term “provider” creates an abyss where there should be a relationship between a doctor/surgeon/physician/physician assistant/nurse practitioner/nurse/therapist/CLINICIAN and patient.  The depersonalization and interchangeability are demoralizing and confusing to me.  I hope we can put this work behind us in 2018.

Sick days for doctors?

I was half way through residency.  Pre 80 hour work week regulations, 2001.  Here is what my schedule looked like:  Monday morning, arrive at hospital to round by 5.  Leave hospital Tuesday evening around 6.  Work out.  Eat a bagel and cream cheese and some carrots for dinner.  Prepare for presentation on esoteric knee fractures while falling asleep.  Repeat.  An easy week was 90 hours.  Most were 100 or more.  And my body had the audacity to fail me.  Fever, chills, vomiting.  I did the unthinkable.  I called in sick.  I paged my attending.  The actual words I heard, “I’ve never heard of a resident calling in sick.  Are you sure?”  I was sure.  In fact, I had barfed again while waiting for the page to be returned.

Times I had slogged through work sick…  pink eye, scabies picked up in the call room, I even passed a kidney stone on call, Not once, but twice, I had a nurse give me a bag of IV fluid mid stomach flu so that I could get through the surgery day.  It was not uncommon to quietly step away from the operating room table to quickly vomit, then scrub back into surgery. Of course this was always accompanied by the question all women residents are used to, “Are you pregnant?”  I was not.  Just sick.

On this day that I was sure I was too sick to work, my nausea was exacerbated by my shame.  I had done the taboo.  I admitted weakness.  There was no system to backfill or cover for sickness.  Because it never happened.  My attending would have to round and see the patients with the medical student.  My work would be done by my superior.  I was terrified of the implications.  I truly thought I might get fired.  I am still ashamed, 17 years later, when I see this surgeon.  I actually am afraid that I am still in trouble.

When I practiced at an academic hospital from 2004-2011, it was still rare for residents to stay home sick and rarer for attending surgeons to miss work for sickness.    I came to work with fevers, runny nose, flu.  I operated the day before I gave birth.  Of these things I am actually no longer proud.

We understand that impaired doctors should not take care of patients.  We understand that doctors cannot be intoxicated.  No drugs.  No alcohol.  Yet even in 2018, doctors work through sleep deprivation and illness.  So many reasons, some good and some awful.  Pride.  Finances.  Patient expectations.  Administrative expectations.  Nursing expectations.

So this year, when I got shingles at the age of 46, I struggled with all of this.  The pain was unreal.  But this is not what kept me home for 4 days.  Actually, I have 2 surgeon friends who took no time off for shingles this year.  What kept me home was the fact that my rash was on my neck and I could not hide it.  And I was contagious.  I take care of young people, babies, and sometimes even older people who do not have the best immune systems.  The guilt was huge.  I am a trumpeter of physician wellness, staying fit and staying sane, doctors are people too…  yet to stay away from work as a sick doctor remains foreign and shameful even to me.

We must work to change this culture.  To promote wellness.  To be brave enough not to go to work when we are sick.

 

 

My Blind Spot

 

 

I am new to twitter.  I am new to writing about being a woman in medicine, a woman in surgery, and a woman in orthopaedics.  I am NOT new to the feeling so beautifully summed up by Dr. Loren Rabinowitz in the New England Journal of Medicine on June 14, 2018.  In her piece, “Recognizing Blind Spots-A Remedy for Gender Bias in Medicine,” Dr. Rabinowitz blew me away by describing an occurrence so familiar to me, a world in which patients receive the care from excellent women physicians without understanding that we are actually physicians.  She tells a story in which a family, grieving and making difficult decisions about a loved one, assumes that her junior resident is the physician in charge because he is a man.  Dr. Rabinowitz continues to put the patient and family ahead of herself, making a conscious decision to avoid a talk about sexism with an “overwhelmed soon to be widow.”  She learns that her intern did not step up to tell the family that she was the senior doctor, because he was the recipient of bias related to the color of his skin.  She writes, “We had both sat through medical school lectures on implicit biases as they relate to patients and health disparities,” without realizing that “it might be our obligation to educate patients about their unconscious biases regarding their health care providers.”  

The first month of my internship at Ben Taub Hospital, in Houston Texas, numbed me and desensitized me.  Within my first week of functioning as a “doctor” I was sticking a chest tube into a patient in shock room 1 just above his tattoo of a swastika.  Many times the unstable patients went directly to the surgical ICU from the shock room.  But not this man.  He stayed in the ER with me for a few hours.  His visitors also had swastikas.  It didn’t occur to me to be scared of them.  I was too tired.  And scared of making a medical mistake.  Of course I said nothing.  To them, to the nurses, to the other doctors, really even to myself.  This was a sick man and it was my job to take care of him.  Maybe I was smart enough to know that there was no way to change him, and nothing to be done.  Words would have been wasted.  This was my lesson, and I carry it with me to this day.  It is not always as blatantly obvious as a jewish intern saving the life of a neo nazi.  Sometimes it is a woman surgeon taking care of a patient who thinks a surgeon should be a man.  And now we have the term “micro-agression.”  

I have become a “communication expert.”  I have the honor of being a part of a group called the Clinician Patient Communication team within Kaiser Permanente.  We coach other doctors about connecting with their patients.  This makes patients happier and more satisfied.  And it also makes doctors happier and more satisfied.  So when I meet a patient who needs surgery, I like to show off my communication skills.  I approach the “s” word (surgery) gingerly  I tell them I know this is routine for me, but a first time rodeo for them.  I patiently tell the patient and their family about the risks and benefits, the pros and cons, the details of the tools and anatomy and recovery.  I am sure to address fears.  This is my wheelhouse.  Except when I get to the part where I ask if they have any other questions, and they ask when they will meet the surgeon.  

I have decided, after 15 years, not to introduce myself as Dr. Weiss.  It feels like a power play.  It doesn’t feel like me.  I walk into the room and shake hands with everyone, even little siblings.  I introduce myself as Jennifer Weiss, one of the orthopaedic doctors.  I do not mention that I am assistant chief.  I was taught not to brag.  And I call them Mr. or Ms. (or Dr.) if they are 18 or older.  I sit and talk at eye level.  I listen with respect.  I connect.  I ask about their lives.  Where do they go to school?  What position do they play?  Do they like their work?  Are they sad about their injury, or scared?  This is the reason I became a doctor, after all, to actually connect with these people.  And introducing myself as Dr. Weiss seems to make the field uneven for me.  Plus, i still look over my shoulder for my dad when I say “Dr. Weiss.”  Imposter syndrome is a topic for another day, but I guess I have it?  

So I thank Dr. Rabinowitz for her compassionate words about women in medicine and our blind spots.  I need to improve my balance, I can connect with, respect, and relate to my patients, yet it is my responsibility to help them also understand that I AM THEIR SURGEON.    I have the privilege and responsibility of cutting into people’s bodies to help them heal.  Whether they are a neo nazi or sexist or racist, I took an oath.  And I need to get over my fear of bragging…

The Post, Women Physician Leadership, The Heim Group, and my mother

Women In Medicine Kaiser Permanente 2018

 

I spent my morning yesterday with women.  Women physicians.  Women physicians in leadership.  Women physicians in leadership and Tammy Hughes from the Heim Group.  If only the first sentence were true, my day would have been unusual for me.  By sentence #4 things got excellent.  Some amazing women physician leaders in my organization, Kaiser Permanente, included me in a room of people that left me in awe.  Dr. Barbara Carnes and Dr. Amy Wolf, 2 simple words for this.  Thank you.  

In 1997, as a senior resident in orthopaedics, Dr. Bettina Gyr, a woman attending in pediatric orthopaedics,  set this story in motion.  She was new to Texas Children’s Hospital and new to practice.  She invited me  and the other woman in my program over for dinner,  Each time a woman entered year 4 or 5 in the program, another woman was accepted.  Mostly 1 woman at a time, with a year of overlap.  The woman who came before me, Dr. Elizabeth Magnabosco, then Elizabeth Dyson, set the bar high.  Higher than high.  Not only was she a great surgeon, she was a great doctor, a great communicator, and a great friend and person.  She didn’t get the memo that when 2 women are surrounded by men that they often don’t stick together and have one another’s backs.  I lucked out with her.  But she was gone and graduated before I even know how to fix an ankle (the most basic orthopaedic surgical procedure).  

When Dr. Bettina Gyr invited us over for dinner, she gave each of us copy of a book called Hardball for Women.  I read it, and learned from it.  I put it away, remembered the book but not where I got it.  In 2012, my mother made a dear friend named Dr. Pat Heim.  They met in the PLATO society, a group of mature overachievers, who gather for “student discussion groups.”  They are retired lawyers and academics, doctors and authors.  They keep up with my mother intellectually, something that we all aspire to,  It turns out that Dr. Pat Heim wrote that book, Hardball for Women.  And when Bettina Gyr and I saw each other at a conference later that year, I remembered her long ago gift and thanked her.  

Yesterday, when I attended the Kaiser Permanente Women in Medicine half day symposium for women in leadership, and I heard our keynote speaker, it took me nearly an hour to put together that Tammy Hughes is the president of Pat Heim’s group.  She spoke about the different lenses worn by men and women, the ingrained differences in behavior and feedback that differ by gender, and the implications this has in working together successfully.  That 1 woman acting like a man is not diversity.  That 2 women in a board room full of men are unlikely to sit near each other and collaborate, it takes 3.  What pearls she dropped, over and over and over again.  And what a full circle she created for me.

The power of Tammy Hughes’ talk synthesizes for me today, as I ride a plane to Hawaii, about to lecture at my all-time favorite event, Aloha update.  Children’s Hospital Los Angeles kindly rotates me onto the faculty of this course for pediatricians every few years.  I take some time out from practicing and polishing my talks to watch “The Post.”  I am blown away.  Meryl Streep’s character, KatharineGraham, is a case study in the challenges of the history of women in the board room.  The grace, the poise, the “feminine” attributes present as the story begins are  cringeworthy as her weakness, her achilles heel.  

Yesterday, I learned the word “codeshifting” from Dr. Christina Kim, a superstar dermatologist.  I have always used the word “shapeshifter” and “chameleon.”  As I climbed to the stage after Tammy Hughes’ talk to bring the group through a “wellness break” of yoga, I acknowledged to this crowd of uber successful women that I was aware that an orthopaedic surgeon leading yoga could not better exemplify this notion of “codeshifting”.  

In “The Post” we see Meryl Streep’s character code shift from feminine dinner hostess, articulate and flattering and beautifully put together, to her board room self.  Men in the board room speak her ideas and take her credit.  She quietly mutters quick and correct answers to important arithmetic questions, and is ignored,  As a viewer of the movie and mentor of women, I am wounded for her.  And mad at her for not speaking up, as she had at her dinner party.  I laugh and cry at the same time as the man sitting next to her is asked to answer the same questions, and gives the same numbers with confidence, followed by distinct acknowledgement.  What makes her perfect as a dinner hostess to America’s then elite aristocracy does not make her successful as their professional leader in any way.

As the story unfolds, Katharine Graham’s character strengthens and grows.  She is shown with her daughter and grandchildren, gathering strength in her bathrobe alongside her sleeping grandchildren.  She quotes Samuel Johnson, “Sir, a woman’s preaching is like a dog’s walking on his hind legs.  It is not done well; but you are surprised to find it done at all.”  Her self awareness is moving.  She then shifts.  She moves to exhibit bravery, she exemplifies a collaborative style concomitant with decisive action.  The respect and support of many of the men she leads is hard won and complete.  Her courage does not make her into a masculine version of herself.  She remains poised and gracious, kind without being nice.  Steven Spielberg has given a case study to Pat Heim in his masterful telling of this story, that time when United States press was saved by a woman.  As Supreme Court Justice Hugo Black wrote, “In the First Amendment, the Founding Fathers gave the free press the protection it must have to fulfill its essential role in our democracy.  The press was to serve the governed, not the governors.”  The year was 1971, Judge Hugo Black died  in 1971, and this was the year I was born.  This rare film that celebrates women with strength and as full, rounded heroines is at its best here.  In today’s #metoo reality, Mr. Spielberg also gives us a history of  #heforshe.  

So thank you to Pat Heim, Hardball for Women, Bettina Gyr, Tammy Hughes, Steven Spielberg and, most of all, Drs. Amy Wolf and Barbara Carnes, for allowing me to come full circle in my now enhanced understanding of women in leadership.  

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