Time to Make a Change… My shift from private practice academics to Kaiser Permanente

There are so many shifting tides in the practice of medicine in 2019. I have just learned of another milestone. For the first time, employed physicians outnumber physicians who are self-employed. This data is reported in a Policy Research Perspective from the American Medical Association by Carol K. Kane, PhD. She reports that younger doctors (under the age of 40) are more likely to be employed physicians. Women are also more likely to be employed physicians. I made the shift from an academic elite private practice to join a large multispecialty medical group at the age of 40, just as I was about to leave this demographic of “young woman.” And I continue to have so much to say about this shift. I am an Orthopedic Surgeon. I have been a doctor for 2 decades now. I became a “surgeon” the year I turned 25, when I graduated from medical school and began internship. The year was 1997, and when I left New York City for Houston I wasn’t even sure what time zone I was entering. The humid southern climate was as foreign as the southern accents and the world renowned medical center called Baylor. My late father, who was also an orthopedic surgeon, moved me into my apartment and crushed the oversized bugs with his size 14 feet (mostly by accident). I was confident in all of the wrong things, and was completely unprepared for the independence expected of an unsupervised intern in surgery. I survived year one, persevered year 2, learned in year 3, struggled in year 4, and finally hit my stride and thrived in years 5 and 6. I moved on to Los Angeles to one of the top pediatric orthopedic fellowships in the world. I entered the mecca of my specialty and surprised myself with my success. I was lifted by my mentors. I was brought into a fold that I never knew existed. I was asked to serve on the Board of Directors of the Pediatric Orthopedic Society. I believed that this honor came because of my academic hospital home. I shocked myself in 2011 when I left the glory of Children’s Hospital Los Angeles and all of the accolades that went along with it. I assumed that I would no longer be embraced by the academic elite. But I had my 3 children to think of. I had sanity to consider. I had predictability to embrace. I was then elevated to the Board of Directors of the mother society of all orthopedic societies, the American Academy of Orthopedic Surgeons. I had underestimated myself, and I had underestimated Kaiser Permanente. My leadership experience from the orthopedic world grew. I was asked to mentor in an elite orthopedic program entitled “Leadership Fellows Program”. Applications are accepted for mentees in this program through age 45. I was 44 when I was invited to mentor. I was elevated to oversee the Communications Council of the Pediatric Orthopedic Society. I was appointed to the Board of Directors of the Ruth Jackson Society of women in orthopedics. My invitations to speak and lecture throughout the country did not slow down. In the 8 years since joining Kaiser Permanente, I have worked hard clinically. I have become respected by my department and was promoted to the position of assistant chief the year after I became partner. I am the Regional Clinical Lead for Pediatric Orthopedics. I am part of the Clinician Patient Communication team, in which I get to do deep work with my partners about how to best connect with our patients with integrity and remain true to ourselves. I take great pride in this program that bolsters our physicians. I am part of the regional team that leads perioperative services, and my niche is in culture. Regional Perioperative Leader for People, Practices, and Systems. My long-term work on this team will focus on diversity and wellness among our surgeons and anesthesiologists. I do all of this while maintaining a full orthopaedic practice. And when I close the door to share a visit with a patient and their family, the room is absolutely no different than the one I inhabited in the mecca a few blocks away. My 12-year-old daughter remembers the days when I rarely returned home in time for dinner, the days when I left for work before she woke up. But happily, my 9-year-old daughter and 7-year-old son do not remember these days. I am an active mother with full support and partnership from my husband of 15 years. I love being a busy surgeon physician, and I believe that whatever I have accomplished as a surgeon and a mother is enhanced by my shift. It is not for everyone. My ego is often checked at the door. But I wouldn’t have it any other way.

My sister and the beginning of her weight loss journey

My sister, Leah, is 6 and a half years younger than me.  She is my best friend.  She is brilliant.  And hilarious.  And engaging.  She is an author and a teacher.  She is a guru of mindfulness.  And for the past many years she has been losing a battle with her weight.  This morning she announced that enough was enough. She did it publicly… https://medium.com/@leahweissauthor/getting-started-for-the-last-time-the-weight-loss-journey-begins-f231f6cb2cfb?fbclid=IwAR3pRrODmEHGnqBcLFI7ncsR9UtUBJNrAdtX_HdtJ9qARNS4ZsDHYP6q5no.

As a pediatric orthopedist, obesity is my enemy in many ways.  When children carry extra weight they are prone to leg deformity, slips in their hip growth plates, and worse outcomes with broken bones.  https://www.anationinmotion.org/ortho-pinion/a-stance-against-obesity-in-children/

Adults who are overweight have a myriad of extra challenges with their bones and joints.  It can be tempting to pursue medical treatment for these aches and pains in the form of pain medication, steroid injections, and even surgery.  Let’s face it.  Weight loss is so much harder than an external fix.  I need to choose every word carefully when I approach this dilemma with my patients.  It can just sound plain mean when they come to seek relief of knee pain from an orthopedist and learn that weight loss is often more effective than joint replacement.  When a vulnerable person wearing a hospital gown sits on a paper sheeted exam table, I can see so much in their sad or angry or discouraged eyes

Last week a young woman came to see me 9 months after I reconstructed her ACL for clearance to get back to full sports and activities  She lost 80 pounds.  Her mother said that she lost a small child.  I saw her pride on every inch of her face.  She listed so many social and physical benefits to her new body habitus.  I added one more, her knee is less likely to become arthritic.

Leah and I grew up with a father who was an orthopedist.  He made us accountable for our aches and pains.  We did not  get notes of excuse to skip the mile run in PE.  When I broke my arm at the age of 8, he actually took a week to believe me enough to take me in for an X-Ray.  So we are 2 sisters that are anything but passive.  When Leah complains about plantar fasciitis or pain in her feet, knee pain or breathlessness, she is quick to preface our conversation with the words, “I know it is because I need to lose weight.”  My sister is aware and determined.  She has played around with strategies to lose weight for a few years, but what I see now in her eyes and her written words is full on determination.  I will be there with her every step and pound of this journey.  

 

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…

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