Don’t Blame the Canary… The Coal Mine is Toxic

This week has been rough. Orthopaedic surgeons lost another great one to suicide. As we virtually support each other through our loss, we compare notes.

Our profession is brutal. We all love what we signed up to do, take care of people who break bones and injure arms and legs and knees and shoulders and hands. We help people with and without doing surgery. And sometimes the part about not recommending surgery can be the hardest.

Most physician specialties have gravitated toward a shift model that creates availability for patients that need urgent and emergent care any time of day or night. The medical and pediatric specialties have specialists called “hospitalists” who are perched to care for anyone who needs care in the hospital. Emergency room physicians and anesthesiologists and radiologists work in shifts to cover all hours of the day and night, relieving one another with predictability.

There are few fields that continue to to function in the antiquated way that orthopaedists function. We work long “business” hours. Then we cover “call” after hours. When we are awake all night, most of us continue to work the next day. We do not get relieved by the next shift. We protect our residents and students from this absurd way of life, but not ourselves.

The administrative burden of patient care in 2020 for surgeons is tremendous. We signed up to work hard: to meet patients where they need to be met. To diagnose, to treat, to operate. But the work surrounding that care that we love grows each year. Administrators have been added to the healthcare workforce to meet these requests, and they now oftentimes outnumber physicians.

As healthcare in 2020 looks to emulate the service industry, administrators often expect physicians to function like employees at Amazon and Marriott and Starbucks. When patients lead their care with the expectation that they are a “customer who is always right” their care can suffer. Sometimes the correct thing to do is not to order an expensive test or do an unnecessary surgery.

Physicians find themselves caught in a web of pathological altruism. The system functions on the back of the professionalism of the doctors, and this professionalism is taken advantage of. Physicians are expected to “please their customer” or make the patient happy at all costs. And giving too much can cause harm.

Ultimately, the responsibility for medical errors lies with the physician, who is at the helm of the team. The policies and procedures and systems are often not physician led. Thus another conundrum for the surgeon.

Pressure to work quickly in the operating room and in clinic amps up more each year. More documentation is expected from the regulators. As reimbursement for each patient visit and surgery decreases, doctors need to see more patients to make ends meet. Resources to support care in the operating room, such as equipment and staff, are dwindling.

Then there is Covid. Covid reintroduced gratitude and respect for physicians and clinicians. But it has made our jobs more dangerous. And many orthopaedists have not been able to do elective surgery. As income has dwindled, some have even had to close their practices.

This is not about lack of resilience in the orthopaedist we lost. This is about a system that has failed our patients and our doctors. I continue to call us to action. The coal mine is toxic, and it is not the canary’s fault.



I Stand with My Sisters in Surgery

We will not stand to be judged

This morning I posted the following on my social media accounts.  

So 3 male surgeons published an article about vascular surgeons and social media. They have the audacity to decide that it is inappropriate for women surgeons to post photos of ourselves in bikinis on social media. No mention of men in swimwear as inappropriate. 

So it is ok for me to be a woman and a surgeon and a mom and to fix people at all hours of the day and night… but these men have declared that it is inappropriate for women surgeons to be pictured in bikinis. And thus the birth of the #medbikini stories. 

As a woman in orthopaedics I stand with the women of vascular surgery.

The support from family and friends, acquaintances and strangers, women, men, surgeons, aspiring surgeons, has poured in.  So I’m inspired to write for the first time in months.  

I wish this article were fiction, or a poor joke.  It was not.  It was published in a peer reviewed journal, The Journal of Vascular Surgery.    Peer reviewed means that other vascular surgeons read it and deemed it true, useful, and appropriate.  And before this, it was presented at the Forty-seventh Annual Symposium of the Society for Clinical Vascular Surgery, Boca Raton, Fla, March 16-20, 2019.  This means that a program committee, vascular surgeons chosen as educational leaders in their field, thought that the research was valid and useful for the surgeons that are members of their organization.  The paper is entitled, “Prevalence of unprofessional social media content among young vascular surgeons.”  The authors set up “neutral” (fake) social media accounts to do their “work.”  One of the “unprofessional” behaviors included in the study was “Inappropriate attire included pictures in underwear, provocative Halloween costumes, and provocative posing in bikinis/swimwear.”  

This morning I saw a post from a vascular surgeon (@lady-surgeon) on instagram using the hashtag #medbikini. She posted photos of herself dressed as a surgeon side by side with photos of her in swimwear.  She wrote, “These are all me… regardless of what I wear, regardless of what I speak out about, regardless of my personal life and what I choose to post on MY social media pages, I am ALL OF THESE WOMEN.  I am a goddamn great surgeon who’s been saving lives for 22 years as a board certified vascular surgeon and for 29 years as a practicing physician/MD.  How dare the (formerly?) esteemed Journal of Vascular Surgery publish a trash article that perpetuates these misogynistic ideas about what qualifies as acceptable, professions or unprofessional behavior, attire and social media content…  She ends by saying “I stand with my sisters in Vascular Surgery” and asks for us to email the editor of the journal.  My story was in answer to her.  And in turn women physicians on facebook, instagram and twitter have rallied.  

I have heard (but cannot yet verify) that the article has been redacted.  But the damage is done.  I have heard from 2 women today who were unwitting “subjects” in this “research,” young vascular surgeons whose accounts were followed by the “researchers.”  They are angry.  I feel violated and judged on their behalf.  

The silver lining of this experience for me is the #heforshe thread on twitter.  Men in orthopaedics have posted photos of themselves in swimwear expressing support for the women in our male dominated field.  

As a woman in orthopaedic surgery, where we make up only 6% of our profession, I stand with the women of vascular surgery.  I stand with all women surgeons.  And all women physicians.  All women in healthcare.  And all women.  We get to be full people, and we get to share that however we choose.  We do not deserve to be trolled and judged in the name of “research.”  We didn’t stand for it today and we won’t in the future.

update: the article has been redacted. Such power in social media and women standing together.

Masks: Your Doctors Don’t Have Enough

I have an N-95 mask.  Because one of my partners had the foresight to buy a pack on amazon a few weeks ago.  

The shortage of protection for doctors and nurses and people taking care of patients is real.  The DMHC maintains that patients may be offered virtual visits, but if they request to be seen in person they must be accommodated.  #flattenthecurve except for us.  And them.  There are reasons that patients need to continue to be seen by an orthopaedic surgeon in person: new fractures, infections, tendon injuries are a few examples.  But knee arthritis and trigger fingers can wait until the other side of this pandemic crisis.  We can guide effectively over the phone.  

My office is full of people making phone calls and fielding video visits, answering emails and messages.  We are trying to keep orthopaedic patients out of the emergency room and urgent care.  We are doctors and nurses working to serve our patients while we help #flattenthecurve.  

The medical field is short on supplies.  Specifically, gear that protects us as we take care of patients is running low and even being rationed.  We have learned from China and Italy that doctors and clinicians who are not protected get sick.  And then we can’t safely take care of patients anymore.  

The construction industry has begun to voluntarily donate their N-95 masks.  My husband just received an email on behalf of a local Children’s Hospital asking for mask donations (he is on an email list for builders).  Nail salons are being asked for their masks.  Yes.  Nail salons.  

Times are scary and unprecedented.  We were down to ONE roll of toilet paper in my home.  I did a back alley trade for wipes with one of my partners, and we now have enough for the week in my house.  The world is upside down.  Gloves and our short supply of sani-wipes were swiped from our patient exam rooms, and are now under lock and key.  

Like any team that works hard in close quarters, our team of doctors, nurses, orthopaedic techs, medical assistants, and others usually bicker and quarrel a bit.  But not this week.  This week we stand together, have each other’s backs.  We check in on each other.  True colors are coming through vibrantly.  But know this.  The front lines are scared.  We want to trust that we are taking whatever means possible to keep ourselves and our families as safe as possible in unsafe times.  And with the shortage of protective gear we know this is not possible.  

The evidence changes on us every day.  Is the virus airborn?  Do we follow workflows and safety procedures for “droplet precautions?”  This means that the virus spreads through droplets from our noses and mouths, and spreads with coughing and sneezing in addition to  touching. For example, MRSA usually spreads by touch, so hand washing is very effective.  The CDC tells us that Covid-19 spreads “through respiratory droplets produced when an infected person coughs or sneezes.”  (cdc.org)  This mainly happens when patients show symptoms, but the virus is also thought to be transmissible before people have symptoms.  The World Health Organization is considering results from a new study showing that the virus can stay suspended in the air in some states of humidity and temperature.  (cnbc.com)  This would increase precaution recommendations to “airborn”.  

Most front line physicians and nurses and clinicians cannot get an N-95 mask, the kind that protects pretty well (95% of the time), unless we are doing a procedure around an airway or secretions.  Right now the evidence is NOT clear.  We do not know if Covid-19 can live in the air.  If it turns out that it does, we are not equipped to protect ourselves.  

We function with a lot of “just in case” precautions in the hospital.  We wear masks and caps and gowns to protect patients from us and us from patients.  The data is not clear that the lengths that we take on a routine basis are necessary.  But an abundance of precaution is our culture, and we are proud of that.  Today we just don’t know.  The evidence is not clear.  But I do know this, we do not have the supplies to support us in an abundance of precaution.  Just like in China and Italy and Seattle, doctors and nurses and front line medical professionals will get sick.  And if we go down, there won’t be enough people to take care of everyone else.  We are here.  We are working.  We are following our moral and ethical obligation and sworn oaths.  We know that we are not protected.  We want you to know too.  So that you can help us by social distancing, supporting our efforts to obtain protective gear, and flattening that dang curve.  

Let it be said that we tried to do what is right

Physicians are on the front line of this pandemic crisis.  I am in a unique role as an orthopaedic surgeon. One of my friends said last week, “if anyone thinks that orthopaedic surgeons are going to be caring for patients with Corona virus, they are sadly mistaken.”  As correct as he is, our duty to lead from where we stand is immense.  

The CDC and the Surgeon General have recommended that we postpone elective surgery.  We do not want to expose our patients to Covid 19.  We do not want to use materials that are in short supply, like masks and protective gowns.  We must understand that the children of doctors and nurses and physician assistants and medical assistants and x-ray technicians and orthopaedic technicians are home and in need of care.  Our resources are short.  We must be ready to use these resources for the waves of sick patients who are likely to come.  Our elective surgeries are cancelled for now. Like joint replacements, and ACL reconstructions, and shoulder arthroscopy and carpel tunnel releases.

What about elective care?  Last week we made the decision to review all charts of patients waiting to see us in my orthopaedic clinic to convert to virtual visits whenever safe and possible.  Social distancing is meant to flatten the curve of spread.  We must avoid patients and healthcare professionals coming into mass contact to address issues that are neither urgent or emergent.  Most patients have received this information with grace and gratitude.  People want to stay safe and to keep those on the front lines safe.  

Some true colors are shining through in the past days.  Support.  Working after hours and on the weekend to do the right thing.  Keeping public health and the greater good in mind, many are rising up, leaning in, and supporting one another.  

And some are not.  This has not landed for some of us.  I had a patient’s mother yell at me last week for the 2 day wait to see her child with a non emergent problem.  I received this without the compassion and empathy that I usually conjure.  I am sure this woman was scared and frustrated, perhaps short on toilet paper, and daunted by the lines around the block at the grocery stores.  She was likely overwhelmed with the mixed messaging coming from the press and our government.  She was absolutely trying to advocate for her child.  And she was certainly not able to see that we are far from business as usual in the orthopaedic clinic.  I cannot blame her.  But I did not have the ability to offer her what she needed, patience and understanding.  

Last night my 13 year old had a sleepover planned with a new friend.  I do not know the friend’s parents.  I should have cancelled.  But I felt bad for the girls, and wanted to let them have one last hurrah before lockdown.  In the middle of the night my 10 year old daughter woke up with a fever.  I did not call the friend’s mother.  I made the call to keep my sick daughter in our room away from the friend.  This was not the right call.  The friend’s family was correctly upset.  All I could do was apologize, and this was received with much appreciated forgiveness.  

Today I went to my favorite Sunday yoga class, usually filled to the brim.  There were 5 students.  And a teacher dealing out everything I needed.  Hard work, deep breath, sweat, and focus.  I am sure even this outlet will shut down within the week.  

We are all so raw.  As parents.  As doctors.  As people.  Our leaders cannot get it right when there is no precedent in contemporary times.  A partner texted me, “our leaders are waiting for word from other leaders, and it all feels like trying to do a U turn in a big rig on a cul-de-sac.”  I have shifted to asking for forgiveness instead of permission.  I must do what seems right.  This is not the time for rule following, as there are no rules.  I am going back to my Hippocratic Oath.  Just trying to do no harm.  

To all of my tribe in medicine, let’s be patient with ourselves.  Let’s support one another.  And let’s remember that we have exited a world of patient led care and “customer” service in medicine.  As we do what we believe is right, we may not have consensus.  The moral and ethical barometer that comes with the art and practice of medicine cannot be dictated or scripted in these times.  Let it be said that we tried to do what was right with courage and even ferocity.  

Ramona Quimby, FDR and My Daughter

Drive or fly?  Although there never seems to be a right answer when planning a trip from southern to northern California, the answer after the trip is always quite clear.  The answer is fly.  We drove. 

Thanksgiving is the best holiday ever in our family.  And this year it got even better.  Two words:  NAPA and chef.  A chance to spend time with my siblings,  their children, and my mother might be one of my biggest pleasures in life.  The planning began early.  And in an effort to save money on plane tickets and hassle of flying, the following ridiculous plan was birthed:  A drive (in the Honda Odyssey minivan with cloth seats) from Los Angeles to Napa, with a stop to pick up my overworked  and less than fully organized husband from his Sacramento office, seemed reasonable in September, and even in October.  But November came around, and I began to recognize the error of my ways.  In an effort to mitigate this mistake, I announced to my mother (she is sane and voluntarily took part in this plan under no duress) and children that we would listen to audiobooks on the trip.  I pushed so hard for Harry Potter.  Amidst pushback from all 3 children, I persevered and downloaded the first of the Harry Potter series.  But somehow I was convinced by Lila to add the Ramona and Beezus collection to the audio library, as a backup plan.  

We started off strong.  Healthy snacks.  No one was carsick.  We even encountered some snowflakes when we stopped for gas just past the grapepevine.  Harry Potter was well loved by my mother, Lila, Ryan and me.  But Colette became obnoxious.  And it became clear that she was scared.  She was scared of the bad guys and the good guys.  And the dead unicorn sent her over the edge.  So we had to revert the backup plan of Ramona and Beezus.  

The superficial similarities between my daughters and Beverly Cleary’s characters from the book written in 1955 are astounding.  This of course speaks to the brilliance of an author who painted a timeless picture of humor in these endearing sisters.  And the narration by Stockard Channing for the audiobook should not go unpraised.

I will start with the basics of the ages.  When we meet Beezus, she is 9 years old, as is my Lila.  Beezus (Beatrice) is reliable, smart, and kind.  She is a pleaser, and she is an ambassador to the world with regard to her ludicrous 4 year old sister, Ramona.  My Colette is 5.   

It deserves mention that there is no counterpart to my 4 year old Ryan in Beverly Cleary’s fictional family.  Ryan has not commented on this omission to date.  

Ramona is far less subtle than my Colette.  As the first chapter unfolded, as we sat in traffic on the 5, I had a great view of Colette in my rearview mirror.  Colette is currently obsessed with her study of the character of Annie/Frannie (amalgamated into 1 character for the purposes of the production of Mary Poppins as put on by the Youth Academy of the Dramatic Arts, at the pre-primary level for ages 5-6.)  Colette has been seen practicing crying with real tears in her bathroom mirror, for instance.  Her solo for this show is “Anything Can Happen.”  This is on the heels of her showstopping performance in the summercamp version of “Fiddler on the Roof”, in which Colette was cast as Schprintze, the 2nd to youngest sister.  As she sang a few lines alone in “Matchmaker” her mother became a tearful mess.  “Matchmaker, matchmaker you know that I’m still very young, please take your time.  Up to this minute I misunderstood that I could get stuck for good.”  Her other solo singing line in “Anatevya” went as follows, “Soon I’ll be a stranger in a strange new land, looking for an old familiar face.”  How was there a dry eye in the house as my babooshka wearing little girl belted these words out?  But I digress…

As I watched Colette listening to the initial description of Ramona (written from the perspective of her older sister, Beezus), I saw her eyeing Lila.  As Beezus described the exasperation of Ramona crashing her community art class, Colette smirked, as if she were Ramona’s accomplice reaching into the pages of a 60 year old fictional book across lines of space and time.  As Beverly Cleary masterfully unfolds her description of an impromptu rainy day party orchestrated by Ramona without the knowledge of her mother and sister, Colette’s eyes sparkled.  The unbelievable thing is that the personalities and humor are so big in this story, that in the year 2015, my kids did not stop to ask about the historical details.  These children were allowed to walk (and bike) around town by themselves.  Dresses were sewn by hand from patterns.  Halloween costumes were also sewn, but masks were purchased.  No face paint.  No glitter.  No fairy princess sparkling 5 piece packages from Party City or Target (or Amazon).  And shopping was done by driving to an actual store in person by the mother in the story.  There is no nanny.  Shows were watched on a television.  

Sometime in book 2 Ramona’s mother went from staying at home full time to accepting a job part time in a pediatrician’s office.  The affects of  this transition on Ramona and Beezus were met with nods by my girls.  I could almost hear Lila and Colette giving words of advice to Ramona and Beezus on the pros and cons of growing up with a working mother.  And here’s where I was caught off guard.  I listened to Stockard Channing’s portrayal of Mrs. Quimby (I do not think Ramona and Beezus’ mother’s first name is divulged) and in the calm, cool portrayal of this voice I found mothering advice.  This mother from 1955 seemed to have taken in the parenting books from 2015.  This mother enjoyed her daughters.  When Ramona ripped up her nemesis’ owl before “Back to School Night,” Mrs. Quimby did not punish or react in a kneejerk way to this bad behavior.  She stopped, and mindfully gathered the information from Ramona, carefully asking “why.”  She did not squelch the spirit and creativity of this hilarious soul.  She also did not allow her older daughter, more of a straight and narrow, mild mannered girl, to be overshadowed in their home.  Not only was Lila identifying with Beezus, and Colette with Ramona, I now found myself aligning (wishful thinking, perhaps) with the great Mrs. Quimby.  

Later that week, Colette and I worked to fill out her November reading list.  Ryan was wearing his reversible superhero mask, debating whether to have the blue or red portion showing.  And Colette was dressed in her devil costume.  I struggled as to whether it was kosher to include audio books.  I succumbed.  To be fair, we had read over 20 books aloud that month.  Page 2 included a sheet to describe Colette’s favorite book of the month.  Without hesitation, she chose Ramona and Beezus.  There is a line to describe why.  Colette of course wrote “I really like Ramona.  She is messy and mean like me.  I am mean to Lila sometimes and I make big messes.  Part of the assignment was a picture, and she drew a picture of a little girl, which she said could be either Ramona or Colette.  

My husband is concerned about this identification of a hero in Ramona.  He has suggested that we ban the series, and has shared his threat with Colette.  She seems undaunted.  Mid drama queen incident at dinner a few nights ago, Jay threatened to cancel her plans to try out for an upcoming production of “Annie.”  Colette held his gaze.  She has begun to listen to Ramona the Brave, and she will remain in character, inspired by her hero.  

Addendum:  Colette and FDR

Have I mentioned Coco’s bright red curly hair?  This, in combination with her theatrics, makes Annie a perfect fit for her.  Her first solo dance this year is to “Tomorrow”.  Her faces and enthusiasm are captivating and over the top.  When the opportunity arose to participate in the play, “Annie”, she had high hopes of landing the lead.  She did not.  Instead she was awarded 2 roles.  1 is the police officer that returns Annie to Mrs. Hannagan after an attempted escape from the orphanage.  The other is FDR.  She was actually quite happy with her roles, and was rehearsing with gusto.  She was pleased about the little girl who plays her wife, Eleanor.  She was practicing her line about the New Deal and singing from the heart about NYC.  3 weeks into rehearsal she came home with a shocking report…  FDR is NOT a girl.  

I took this shock as a compliment.  It did not occur to my 6 year old daughter that a president of the United States would be a boy, then, now, or in the future.  Her love for Barack O’Bama aside (her twin cousins actually had a Barack O’Bama birthday theme the year they turned 9), Coco has begun her conscious years believing in gender and sex equality.  So my husband and I are high 5ing at this juncture. 

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