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Noise in medicine
A 26-year-old woman who reports a history of acyclovir-resistant herpes complains of a recurring, stinging rash around her mouth. Topical tacrolimus made it worse, she said. On exam, she has somewhat grouped pustules on her cutaneous lip. I mentioned her to colleagues, saying: “I’ve a patient with acyclovir-resistant herpes who isn’t improving on high-dose Valtrex.” They proffered a few alternative diagnoses and treatment recommendations. I tried several to no avail.
(it is after all only one condition). Nobel Prize–winning economist Daniel Kahneman, PhD, with two other authors, has written a brilliant book about this cognitive unreliability called “Noise: A Flaw in Human Judgment” (New York: Hachette Book Group, 2021).
Both bias and noise create trouble for us. Although biases get more attention, noise is both more prevalent and insidious. In a 2016 article, Dr. Kahneman and coauthors use a bathroom scale as an analogy to explain the difference. “We would say that the scale is biased if its readings are generally either too high or too low. A scale that consistently underestimates true weight by exactly 4 pounds is seriously biased but free of noise. A scale that gives two different readings when you step on it twice is noisy.” In the case presented, “measurements” by me and my colleagues were returning different “readings.” There is one true diagnosis and best treatment, yet because of noise, we waste time and resources by not getting it right the first time.
[embed:render:related:node:240288]
There is also evidence of bias in this case. For example, there’s probably some confirmation bias: The patient said she has a history of antiviral-resistant herpes; therefore, her rash might appear to be herpes. Also there might be salience bias: it’s easy to see how prominent pustules might be herpes simplex virus. Noise is an issue in many misdiagnoses, but trickier to see. In most instances, we don’t have the opportunity to get multiple assessments of the same case. When examined though, interrater reliability in medicine is often found to be shockingly low, an indication of how much noise there is in our clinical judgments. This leads to waste, frustration – and can even be dangerous when we’re trying to diagnose cancers such as melanoma, lung, or breast cancer.
Dr. Kahneman and colleagues have excellent recommendations on how to reduce noise, such as tips for good decision hygiene (e.g., using differential diagnoses) and using algorithms (e.g., calculating Apgar or LACE scores). I also liked their strategy of aggregating expert opinions. Fascinatingly, averaging multiple independent assessments is mathematically guaranteed to reduce noise. (God, I love economists). This is true of measurements and opinions: If you use 100 judgments for a case, you reduce noise by 90% (the noise is divided by the square root of the number of judgments averaged). So 20 colleagues’ opinions would reduce noise by almost 80%. However, those 20 opinions must be independent to avoid spurious agreement. (Again, math for the win.)
I showed photos of my patient to a few other dermatologists. They independently returned the same result: perioral dermatitis. This was the correct diagnosis and reminded me why grand rounds and tumor boards are such a great help. Multiple, independent assessments are more likely to get it right than just one opinion because we are canceling out the noise. But remember, grand rounds has to be old-school style – no looking at your coresident answers before giving yours!
Our patient cleared after restarting her topical tacrolimus and a bit of doxycycline. Credit the wisdom of the crowd. Reassuringly though, Dr. Kahneman also shows that expertise does matter in minimizing error. So that fellowship you did was still a great idea.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He reports having no conflicts of interest. Write to him at dermnews@mdedge.com.
A 26-year-old woman who reports a history of acyclovir-resistant herpes complains of a recurring, stinging rash around her mouth. Topical tacrolimus made it worse, she said. On exam, she has somewhat grouped pustules on her cutaneous lip. I mentioned her to colleagues, saying: “I’ve a patient with acyclovir-resistant herpes who isn’t improving on high-dose Valtrex.” They proffered a few alternative diagnoses and treatment recommendations. I tried several to no avail.
(it is after all only one condition). Nobel Prize–winning economist Daniel Kahneman, PhD, with two other authors, has written a brilliant book about this cognitive unreliability called “Noise: A Flaw in Human Judgment” (New York: Hachette Book Group, 2021).
Both bias and noise create trouble for us. Although biases get more attention, noise is both more prevalent and insidious. In a 2016 article, Dr. Kahneman and coauthors use a bathroom scale as an analogy to explain the difference. “We would say that the scale is biased if its readings are generally either too high or too low. A scale that consistently underestimates true weight by exactly 4 pounds is seriously biased but free of noise. A scale that gives two different readings when you step on it twice is noisy.” In the case presented, “measurements” by me and my colleagues were returning different “readings.” There is one true diagnosis and best treatment, yet because of noise, we waste time and resources by not getting it right the first time.
[embed:render:related:node:240288]
There is also evidence of bias in this case. For example, there’s probably some confirmation bias: The patient said she has a history of antiviral-resistant herpes; therefore, her rash might appear to be herpes. Also there might be salience bias: it’s easy to see how prominent pustules might be herpes simplex virus. Noise is an issue in many misdiagnoses, but trickier to see. In most instances, we don’t have the opportunity to get multiple assessments of the same case. When examined though, interrater reliability in medicine is often found to be shockingly low, an indication of how much noise there is in our clinical judgments. This leads to waste, frustration – and can even be dangerous when we’re trying to diagnose cancers such as melanoma, lung, or breast cancer.
Dr. Kahneman and colleagues have excellent recommendations on how to reduce noise, such as tips for good decision hygiene (e.g., using differential diagnoses) and using algorithms (e.g., calculating Apgar or LACE scores). I also liked their strategy of aggregating expert opinions. Fascinatingly, averaging multiple independent assessments is mathematically guaranteed to reduce noise. (God, I love economists). This is true of measurements and opinions: If you use 100 judgments for a case, you reduce noise by 90% (the noise is divided by the square root of the number of judgments averaged). So 20 colleagues’ opinions would reduce noise by almost 80%. However, those 20 opinions must be independent to avoid spurious agreement. (Again, math for the win.)
I showed photos of my patient to a few other dermatologists. They independently returned the same result: perioral dermatitis. This was the correct diagnosis and reminded me why grand rounds and tumor boards are such a great help. Multiple, independent assessments are more likely to get it right than just one opinion because we are canceling out the noise. But remember, grand rounds has to be old-school style – no looking at your coresident answers before giving yours!
Our patient cleared after restarting her topical tacrolimus and a bit of doxycycline. Credit the wisdom of the crowd. Reassuringly though, Dr. Kahneman also shows that expertise does matter in minimizing error. So that fellowship you did was still a great idea.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He reports having no conflicts of interest. Write to him at dermnews@mdedge.com.
A 26-year-old woman who reports a history of acyclovir-resistant herpes complains of a recurring, stinging rash around her mouth. Topical tacrolimus made it worse, she said. On exam, she has somewhat grouped pustules on her cutaneous lip. I mentioned her to colleagues, saying: “I’ve a patient with acyclovir-resistant herpes who isn’t improving on high-dose Valtrex.” They proffered a few alternative diagnoses and treatment recommendations. I tried several to no avail.
(it is after all only one condition). Nobel Prize–winning economist Daniel Kahneman, PhD, with two other authors, has written a brilliant book about this cognitive unreliability called “Noise: A Flaw in Human Judgment” (New York: Hachette Book Group, 2021).
Both bias and noise create trouble for us. Although biases get more attention, noise is both more prevalent and insidious. In a 2016 article, Dr. Kahneman and coauthors use a bathroom scale as an analogy to explain the difference. “We would say that the scale is biased if its readings are generally either too high or too low. A scale that consistently underestimates true weight by exactly 4 pounds is seriously biased but free of noise. A scale that gives two different readings when you step on it twice is noisy.” In the case presented, “measurements” by me and my colleagues were returning different “readings.” There is one true diagnosis and best treatment, yet because of noise, we waste time and resources by not getting it right the first time.
[embed:render:related:node:240288]
There is also evidence of bias in this case. For example, there’s probably some confirmation bias: The patient said she has a history of antiviral-resistant herpes; therefore, her rash might appear to be herpes. Also there might be salience bias: it’s easy to see how prominent pustules might be herpes simplex virus. Noise is an issue in many misdiagnoses, but trickier to see. In most instances, we don’t have the opportunity to get multiple assessments of the same case. When examined though, interrater reliability in medicine is often found to be shockingly low, an indication of how much noise there is in our clinical judgments. This leads to waste, frustration – and can even be dangerous when we’re trying to diagnose cancers such as melanoma, lung, or breast cancer.
Dr. Kahneman and colleagues have excellent recommendations on how to reduce noise, such as tips for good decision hygiene (e.g., using differential diagnoses) and using algorithms (e.g., calculating Apgar or LACE scores). I also liked their strategy of aggregating expert opinions. Fascinatingly, averaging multiple independent assessments is mathematically guaranteed to reduce noise. (God, I love economists). This is true of measurements and opinions: If you use 100 judgments for a case, you reduce noise by 90% (the noise is divided by the square root of the number of judgments averaged). So 20 colleagues’ opinions would reduce noise by almost 80%. However, those 20 opinions must be independent to avoid spurious agreement. (Again, math for the win.)
I showed photos of my patient to a few other dermatologists. They independently returned the same result: perioral dermatitis. This was the correct diagnosis and reminded me why grand rounds and tumor boards are such a great help. Multiple, independent assessments are more likely to get it right than just one opinion because we are canceling out the noise. But remember, grand rounds has to be old-school style – no looking at your coresident answers before giving yours!
Our patient cleared after restarting her topical tacrolimus and a bit of doxycycline. Credit the wisdom of the crowd. Reassuringly though, Dr. Kahneman also shows that expertise does matter in minimizing error. So that fellowship you did was still a great idea.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. He reports having no conflicts of interest. Write to him at dermnews@mdedge.com.
The hateful patient
A 64-year-old White woman with very few medical problems complains of bug bites. She had seen no bugs and had no visible bites. There is no rash. “So what bit me?” she asked, pulling her mask down for emphasis. How should I know? I thought, but didn’t say. She and I have been through this many times.
Before I could respond, she filled the pause with her usual complaints including how hard it is to get an appointment with me and how every appointment with me is a waste of her time. Ignoring the contradistinction of her charges, I took some satisfaction realizing she has just given me a topic to write about: The hateful patient.
They are frustrating, troublesome, rude, sometimes racist, misogynistic, depressing, hopeless, and disheartening. They call you, email you, and come to see you just to annoy you (so it seems). And they’re everywhere. According to one study, nearly one in six are “difficult patients.” It feels like more lately because the vaccine has brought haters back into clinic, just to get us.
But hateful patients aren’t new. In 1978, James E. Groves, MD, a Harvard psychiatrist, wrote a now-classic New England Journal of Medicine article about them called: Taking Care of the Hateful Patient. Even Osler, back in 1889, covered these patients in his lecture to University of Pennsylvania students, advising us to “deal gently with this deliciously credulous old human nature in which we work ... restrain your indignation.” But like much of Osler’s advice, it is easier said than done.
Dr. Groves is more helpful, and presents a model to understand them. Difficult patients, as we’d now call them, fall into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejectors, and self-destructive deniers. It’s Dr. Groves’s bottom line I found insightful. He says that, when patients create negative feelings in us, we’re more likely to make errors. He then gives sound advice: Set firm boundaries and learn to counter the countertransference these patients provoke. Don’t disavow or discharge, Dr. Groves advises, redirect these emotions to motivate you to dig deeper. There you’ll find clinical data that will facilitate understanding and enable better patient management. Yes, easier said.
[embed:render:related:node:238783]
In addition to Dr. Groves’s analysis of how we harm these patients, I’d add that these disagreeable, malingering patients also harm us doctors. The hangover from a difficult patient encounter can linger for several appointments later or, worse, carryover to home. And now with patient emails proliferating, demanding patients behave as if we have an inexhaustible ability to engage them. We don’t. Many physicians are struggling to care at all; their low empathy battery warnings are blinking red, less than 1% remaining.
What is toxic to us doctors is the maelstrom of cognitive dissonance these patients create in us. Have you ever felt relief to learn a difficult patient has “finally” died? How could we think such a thing?! Didn’t we choose medicine instead of Wall Street because we care about people? But manipulative patients can make us care less. We even use secret language with each other to protect ourselves from them, those GOMERs (get out of my emergency room), bouncebacks, patients with status dramaticus, and those ornery FTDs (failure to die). Save yourself, we say to each other, this patient will kill you.
Caring for my somatizing 64-year-old patient has been difficult, but writing this has helped me reframe our interaction. Unsurprisingly, at the end of her failed visit she asked when she could see me again. “I need to schedule now because I have to find a neighbor to watch my dogs. It takes two buses to come here and I can’t take them with me.” Ah, there’s the clinical data Dr. Groves said I’d find – she’s not here to hurt me, she’s here because I’m all she’s got. At least for this difficult patient, I have a plan. At the bottom of my note I type “RTC 3 mo.”
Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
A 64-year-old White woman with very few medical problems complains of bug bites. She had seen no bugs and had no visible bites. There is no rash. “So what bit me?” she asked, pulling her mask down for emphasis. How should I know? I thought, but didn’t say. She and I have been through this many times.
Before I could respond, she filled the pause with her usual complaints including how hard it is to get an appointment with me and how every appointment with me is a waste of her time. Ignoring the contradistinction of her charges, I took some satisfaction realizing she has just given me a topic to write about: The hateful patient.
They are frustrating, troublesome, rude, sometimes racist, misogynistic, depressing, hopeless, and disheartening. They call you, email you, and come to see you just to annoy you (so it seems). And they’re everywhere. According to one study, nearly one in six are “difficult patients.” It feels like more lately because the vaccine has brought haters back into clinic, just to get us.
But hateful patients aren’t new. In 1978, James E. Groves, MD, a Harvard psychiatrist, wrote a now-classic New England Journal of Medicine article about them called: Taking Care of the Hateful Patient. Even Osler, back in 1889, covered these patients in his lecture to University of Pennsylvania students, advising us to “deal gently with this deliciously credulous old human nature in which we work ... restrain your indignation.” But like much of Osler’s advice, it is easier said than done.
Dr. Groves is more helpful, and presents a model to understand them. Difficult patients, as we’d now call them, fall into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejectors, and self-destructive deniers. It’s Dr. Groves’s bottom line I found insightful. He says that, when patients create negative feelings in us, we’re more likely to make errors. He then gives sound advice: Set firm boundaries and learn to counter the countertransference these patients provoke. Don’t disavow or discharge, Dr. Groves advises, redirect these emotions to motivate you to dig deeper. There you’ll find clinical data that will facilitate understanding and enable better patient management. Yes, easier said.
[embed:render:related:node:238783]
In addition to Dr. Groves’s analysis of how we harm these patients, I’d add that these disagreeable, malingering patients also harm us doctors. The hangover from a difficult patient encounter can linger for several appointments later or, worse, carryover to home. And now with patient emails proliferating, demanding patients behave as if we have an inexhaustible ability to engage them. We don’t. Many physicians are struggling to care at all; their low empathy battery warnings are blinking red, less than 1% remaining.
What is toxic to us doctors is the maelstrom of cognitive dissonance these patients create in us. Have you ever felt relief to learn a difficult patient has “finally” died? How could we think such a thing?! Didn’t we choose medicine instead of Wall Street because we care about people? But manipulative patients can make us care less. We even use secret language with each other to protect ourselves from them, those GOMERs (get out of my emergency room), bouncebacks, patients with status dramaticus, and those ornery FTDs (failure to die). Save yourself, we say to each other, this patient will kill you.
Caring for my somatizing 64-year-old patient has been difficult, but writing this has helped me reframe our interaction. Unsurprisingly, at the end of her failed visit she asked when she could see me again. “I need to schedule now because I have to find a neighbor to watch my dogs. It takes two buses to come here and I can’t take them with me.” Ah, there’s the clinical data Dr. Groves said I’d find – she’s not here to hurt me, she’s here because I’m all she’s got. At least for this difficult patient, I have a plan. At the bottom of my note I type “RTC 3 mo.”
Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
A 64-year-old White woman with very few medical problems complains of bug bites. She had seen no bugs and had no visible bites. There is no rash. “So what bit me?” she asked, pulling her mask down for emphasis. How should I know? I thought, but didn’t say. She and I have been through this many times.
Before I could respond, she filled the pause with her usual complaints including how hard it is to get an appointment with me and how every appointment with me is a waste of her time. Ignoring the contradistinction of her charges, I took some satisfaction realizing she has just given me a topic to write about: The hateful patient.
They are frustrating, troublesome, rude, sometimes racist, misogynistic, depressing, hopeless, and disheartening. They call you, email you, and come to see you just to annoy you (so it seems). And they’re everywhere. According to one study, nearly one in six are “difficult patients.” It feels like more lately because the vaccine has brought haters back into clinic, just to get us.
But hateful patients aren’t new. In 1978, James E. Groves, MD, a Harvard psychiatrist, wrote a now-classic New England Journal of Medicine article about them called: Taking Care of the Hateful Patient. Even Osler, back in 1889, covered these patients in his lecture to University of Pennsylvania students, advising us to “deal gently with this deliciously credulous old human nature in which we work ... restrain your indignation.” But like much of Osler’s advice, it is easier said than done.
Dr. Groves is more helpful, and presents a model to understand them. Difficult patients, as we’d now call them, fall into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejectors, and self-destructive deniers. It’s Dr. Groves’s bottom line I found insightful. He says that, when patients create negative feelings in us, we’re more likely to make errors. He then gives sound advice: Set firm boundaries and learn to counter the countertransference these patients provoke. Don’t disavow or discharge, Dr. Groves advises, redirect these emotions to motivate you to dig deeper. There you’ll find clinical data that will facilitate understanding and enable better patient management. Yes, easier said.
[embed:render:related:node:238783]
In addition to Dr. Groves’s analysis of how we harm these patients, I’d add that these disagreeable, malingering patients also harm us doctors. The hangover from a difficult patient encounter can linger for several appointments later or, worse, carryover to home. And now with patient emails proliferating, demanding patients behave as if we have an inexhaustible ability to engage them. We don’t. Many physicians are struggling to care at all; their low empathy battery warnings are blinking red, less than 1% remaining.
What is toxic to us doctors is the maelstrom of cognitive dissonance these patients create in us. Have you ever felt relief to learn a difficult patient has “finally” died? How could we think such a thing?! Didn’t we choose medicine instead of Wall Street because we care about people? But manipulative patients can make us care less. We even use secret language with each other to protect ourselves from them, those GOMERs (get out of my emergency room), bouncebacks, patients with status dramaticus, and those ornery FTDs (failure to die). Save yourself, we say to each other, this patient will kill you.
Caring for my somatizing 64-year-old patient has been difficult, but writing this has helped me reframe our interaction. Unsurprisingly, at the end of her failed visit she asked when she could see me again. “I need to schedule now because I have to find a neighbor to watch my dogs. It takes two buses to come here and I can’t take them with me.” Ah, there’s the clinical data Dr. Groves said I’d find – she’s not here to hurt me, she’s here because I’m all she’s got. At least for this difficult patient, I have a plan. At the bottom of my note I type “RTC 3 mo.”
Dr. Benabio is director of healthcare transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Artificial intelligence wish list
Dear big-tech AI company,
I do understand, the benefits of artificial intelligence today are already profound and protean. Thanks to AI, I can translate Italian to English in real time in the same voice as an Italian speaker. I can be driven home autonomously by our Tesla. AI helps keep me safe by predicting crimes, on time by predicting traffic, and healthy by designing plant proteins that taste just like beef. I can even use AI to build a sprinkler to keep people off my new lawn.
In medicine, the AI news is so good that a frisson of excitement spreads vertically and horizontally across all health care. AI can detect pulmonary nodules, identify melanomas, develop new drugs – speed vaccine discovery! – and detect malignant cells on a biopsy slide. It can help predict who is going to crash in the ICU and recognize when someone is about to fall out of bed in the surgical unit. Even just this sampling of benefits proves how significant and impactful AI is in improving quality of life for patients and populations.
However, much of what I do every day in medicine cannot be solved with a neat quantitative analysis. The vast majority of my patients do not have a melanoma to be diagnosed or diabetic retinopathy to be scanned. What they want and need is time spent with me, their doctor. Although the schedule says I have 15 minutes (insufficient to begin with), patients are running late and are double booked, and I’ve loads of notes to type, medications to review, and messages to answer. Most days, I have only a fraction of 15 minutes to spend face to face with each patient.
Can AI please help us? How about reviewing the reams of data from my patient’s chart and presenting it to me succinctly? Rather than my tediously clicking through pathology reports, just summarize what skin cancers my patient has had and when. Rather than learning that my patient already failed Protopic a year ago, let me know that before I sign the order and promise: “Now, this ointment will work.” Even better, suggest alternative treatments that I might not be thinking of and which might do just the trick. Oh, and given my EMR has all the data required to determine billing codes, can you just drop that in for me when I’m done? Lastly, if the patient’s insurance is going to reject this claim or that medication, can AI please complete the authorization/paperwork/signed notary document/letter from U.S. senator that will be needed for it to be accepted?
I know this is possible. If we can blast a 70-year-old businessman into space on a private jet, surely you can invent an AI that gives us more time to spend with patients. Proposals postmarked by Dec. 31, 2021, please.
I’m sincerely yours,
Jeff Benabio, MD, MBA
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Dear big-tech AI company,
I do understand, the benefits of artificial intelligence today are already profound and protean. Thanks to AI, I can translate Italian to English in real time in the same voice as an Italian speaker. I can be driven home autonomously by our Tesla. AI helps keep me safe by predicting crimes, on time by predicting traffic, and healthy by designing plant proteins that taste just like beef. I can even use AI to build a sprinkler to keep people off my new lawn.
In medicine, the AI news is so good that a frisson of excitement spreads vertically and horizontally across all health care. AI can detect pulmonary nodules, identify melanomas, develop new drugs – speed vaccine discovery! – and detect malignant cells on a biopsy slide. It can help predict who is going to crash in the ICU and recognize when someone is about to fall out of bed in the surgical unit. Even just this sampling of benefits proves how significant and impactful AI is in improving quality of life for patients and populations.
However, much of what I do every day in medicine cannot be solved with a neat quantitative analysis. The vast majority of my patients do not have a melanoma to be diagnosed or diabetic retinopathy to be scanned. What they want and need is time spent with me, their doctor. Although the schedule says I have 15 minutes (insufficient to begin with), patients are running late and are double booked, and I’ve loads of notes to type, medications to review, and messages to answer. Most days, I have only a fraction of 15 minutes to spend face to face with each patient.
Can AI please help us? How about reviewing the reams of data from my patient’s chart and presenting it to me succinctly? Rather than my tediously clicking through pathology reports, just summarize what skin cancers my patient has had and when. Rather than learning that my patient already failed Protopic a year ago, let me know that before I sign the order and promise: “Now, this ointment will work.” Even better, suggest alternative treatments that I might not be thinking of and which might do just the trick. Oh, and given my EMR has all the data required to determine billing codes, can you just drop that in for me when I’m done? Lastly, if the patient’s insurance is going to reject this claim or that medication, can AI please complete the authorization/paperwork/signed notary document/letter from U.S. senator that will be needed for it to be accepted?
I know this is possible. If we can blast a 70-year-old businessman into space on a private jet, surely you can invent an AI that gives us more time to spend with patients. Proposals postmarked by Dec. 31, 2021, please.
I’m sincerely yours,
Jeff Benabio, MD, MBA
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Dear big-tech AI company,
I do understand, the benefits of artificial intelligence today are already profound and protean. Thanks to AI, I can translate Italian to English in real time in the same voice as an Italian speaker. I can be driven home autonomously by our Tesla. AI helps keep me safe by predicting crimes, on time by predicting traffic, and healthy by designing plant proteins that taste just like beef. I can even use AI to build a sprinkler to keep people off my new lawn.
In medicine, the AI news is so good that a frisson of excitement spreads vertically and horizontally across all health care. AI can detect pulmonary nodules, identify melanomas, develop new drugs – speed vaccine discovery! – and detect malignant cells on a biopsy slide. It can help predict who is going to crash in the ICU and recognize when someone is about to fall out of bed in the surgical unit. Even just this sampling of benefits proves how significant and impactful AI is in improving quality of life for patients and populations.
However, much of what I do every day in medicine cannot be solved with a neat quantitative analysis. The vast majority of my patients do not have a melanoma to be diagnosed or diabetic retinopathy to be scanned. What they want and need is time spent with me, their doctor. Although the schedule says I have 15 minutes (insufficient to begin with), patients are running late and are double booked, and I’ve loads of notes to type, medications to review, and messages to answer. Most days, I have only a fraction of 15 minutes to spend face to face with each patient.
Can AI please help us? How about reviewing the reams of data from my patient’s chart and presenting it to me succinctly? Rather than my tediously clicking through pathology reports, just summarize what skin cancers my patient has had and when. Rather than learning that my patient already failed Protopic a year ago, let me know that before I sign the order and promise: “Now, this ointment will work.” Even better, suggest alternative treatments that I might not be thinking of and which might do just the trick. Oh, and given my EMR has all the data required to determine billing codes, can you just drop that in for me when I’m done? Lastly, if the patient’s insurance is going to reject this claim or that medication, can AI please complete the authorization/paperwork/signed notary document/letter from U.S. senator that will be needed for it to be accepted?
I know this is possible. If we can blast a 70-year-old businessman into space on a private jet, surely you can invent an AI that gives us more time to spend with patients. Proposals postmarked by Dec. 31, 2021, please.
I’m sincerely yours,
Jeff Benabio, MD, MBA
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
The good old days
“It’s good to be in something from the ground floor. I came too late for that. ... But lately, I’m getting the feeling that I came in at the end. The best is over.” –Tony Soprano
For me, I’m unsure. Sometimes it feels like our best days are behind us. When I was a kid, we explored life in pond water, watching water fleas and hydra swim under our Child World toy microscopes. Today, kids learn to eat Tide Pods from TikTok. Back when I was young, a doctor’s appointment was a special occasion! My brothers and I had a bath and got dressed in our Sunday best for our appointment with Dr. Bellin, a genteel, gray-haired pediatrician who worked out of his Victorian office with wooden floors and crystal door handles. Contrast that with the appointment I had with a patient the other day, done by telephone while she was in line ordering at Starbucks. I waited patiently for her to give her order.
This ache I feel for the past is called nostalgia. At one time, it was a diagnosable condition. It was first used by Dr. Johannes Hofer in the 17th century to describe Swiss soldiers fighting in foreign lands. From the Greek, it means “homecoming pain.” Although over time nostalgia has lost its clinical meaning, the feeling of yearning for the past has dramatically gained in prevalence. The word “nostalgia” appears more in print now than at any point since 1800. We are most nostalgic during times of duress, it seems. This, no doubt, is because it’s comforting to think we’d be better off back in pastoral, idyll times, back when work ended at 5 p.m. and cotton balls were soaked in alcohol and office visits ended with a lollipop on a loop.
Of course, the good old days weren’t really better. We have a selective view of history – as many things were contemptible or bad then as now. Yes, Dr. Bellin was the consummate professional, but thank goodness, I didn’t have acute lymphocytic leukemia or Haemophilus influenzae type B or even suffocate under a pile of blankets while sleeping on my stomach. Without doubt, clinically we’re much better today. Also back then, there was hardly a consideration for atrocious racial disparities in care. We’ve not come far, but we are at least better off today than a few decades ago. And what about medicine as a profession? Although he had loads of autonomy and respect, Dr. Bellin also started every day of his 50-year career at 6 a.m. rounding in the newborn nursery before seeing patients in the office 6 days a week. Not many of us would trade our practice for his.
Yet, there’s reasons to be nostalgic. Chart notes might have been barely legible, but at least they served a purpose. The problem-oriented medical record was intended to logically capture and organize data. SOAP notes were invented to help us think better, to get diagnoses correct, to succinctly see progress. Today, notes are written for administrators and payers and patients. As a result, they’re often useless to us.
And although it may have been inconvenient to sit in the waiting room reading Highlights magazine, I’m unsure it was a worse user experience, compared with a chain pharmacy “virtual” doctor visit. (Particularly because you could always drop pennies down the large hot-air iron floor grate in the corner).
The thrumming undercurrent of progress promises artificial intelligence and genomics and wearable diagnostics in our future. But the assumption is the new things will be better suited to our needs than the old. Sometimes, they are not. Sometimes technology diminishes us instead of enhancing us.
I cannot count how many times I’ve hit my head or whacked my shin because our Tesla Model X doors open by magic and of their own accord. Back when I was young, we opened car doors by pulling on the door handle. I sometimes miss those days.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
“It’s good to be in something from the ground floor. I came too late for that. ... But lately, I’m getting the feeling that I came in at the end. The best is over.” –Tony Soprano
For me, I’m unsure. Sometimes it feels like our best days are behind us. When I was a kid, we explored life in pond water, watching water fleas and hydra swim under our Child World toy microscopes. Today, kids learn to eat Tide Pods from TikTok. Back when I was young, a doctor’s appointment was a special occasion! My brothers and I had a bath and got dressed in our Sunday best for our appointment with Dr. Bellin, a genteel, gray-haired pediatrician who worked out of his Victorian office with wooden floors and crystal door handles. Contrast that with the appointment I had with a patient the other day, done by telephone while she was in line ordering at Starbucks. I waited patiently for her to give her order.
This ache I feel for the past is called nostalgia. At one time, it was a diagnosable condition. It was first used by Dr. Johannes Hofer in the 17th century to describe Swiss soldiers fighting in foreign lands. From the Greek, it means “homecoming pain.” Although over time nostalgia has lost its clinical meaning, the feeling of yearning for the past has dramatically gained in prevalence. The word “nostalgia” appears more in print now than at any point since 1800. We are most nostalgic during times of duress, it seems. This, no doubt, is because it’s comforting to think we’d be better off back in pastoral, idyll times, back when work ended at 5 p.m. and cotton balls were soaked in alcohol and office visits ended with a lollipop on a loop.
Of course, the good old days weren’t really better. We have a selective view of history – as many things were contemptible or bad then as now. Yes, Dr. Bellin was the consummate professional, but thank goodness, I didn’t have acute lymphocytic leukemia or Haemophilus influenzae type B or even suffocate under a pile of blankets while sleeping on my stomach. Without doubt, clinically we’re much better today. Also back then, there was hardly a consideration for atrocious racial disparities in care. We’ve not come far, but we are at least better off today than a few decades ago. And what about medicine as a profession? Although he had loads of autonomy and respect, Dr. Bellin also started every day of his 50-year career at 6 a.m. rounding in the newborn nursery before seeing patients in the office 6 days a week. Not many of us would trade our practice for his.
Yet, there’s reasons to be nostalgic. Chart notes might have been barely legible, but at least they served a purpose. The problem-oriented medical record was intended to logically capture and organize data. SOAP notes were invented to help us think better, to get diagnoses correct, to succinctly see progress. Today, notes are written for administrators and payers and patients. As a result, they’re often useless to us.
And although it may have been inconvenient to sit in the waiting room reading Highlights magazine, I’m unsure it was a worse user experience, compared with a chain pharmacy “virtual” doctor visit. (Particularly because you could always drop pennies down the large hot-air iron floor grate in the corner).
The thrumming undercurrent of progress promises artificial intelligence and genomics and wearable diagnostics in our future. But the assumption is the new things will be better suited to our needs than the old. Sometimes, they are not. Sometimes technology diminishes us instead of enhancing us.
I cannot count how many times I’ve hit my head or whacked my shin because our Tesla Model X doors open by magic and of their own accord. Back when I was young, we opened car doors by pulling on the door handle. I sometimes miss those days.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
“It’s good to be in something from the ground floor. I came too late for that. ... But lately, I’m getting the feeling that I came in at the end. The best is over.” –Tony Soprano
For me, I’m unsure. Sometimes it feels like our best days are behind us. When I was a kid, we explored life in pond water, watching water fleas and hydra swim under our Child World toy microscopes. Today, kids learn to eat Tide Pods from TikTok. Back when I was young, a doctor’s appointment was a special occasion! My brothers and I had a bath and got dressed in our Sunday best for our appointment with Dr. Bellin, a genteel, gray-haired pediatrician who worked out of his Victorian office with wooden floors and crystal door handles. Contrast that with the appointment I had with a patient the other day, done by telephone while she was in line ordering at Starbucks. I waited patiently for her to give her order.
This ache I feel for the past is called nostalgia. At one time, it was a diagnosable condition. It was first used by Dr. Johannes Hofer in the 17th century to describe Swiss soldiers fighting in foreign lands. From the Greek, it means “homecoming pain.” Although over time nostalgia has lost its clinical meaning, the feeling of yearning for the past has dramatically gained in prevalence. The word “nostalgia” appears more in print now than at any point since 1800. We are most nostalgic during times of duress, it seems. This, no doubt, is because it’s comforting to think we’d be better off back in pastoral, idyll times, back when work ended at 5 p.m. and cotton balls were soaked in alcohol and office visits ended with a lollipop on a loop.
Of course, the good old days weren’t really better. We have a selective view of history – as many things were contemptible or bad then as now. Yes, Dr. Bellin was the consummate professional, but thank goodness, I didn’t have acute lymphocytic leukemia or Haemophilus influenzae type B or even suffocate under a pile of blankets while sleeping on my stomach. Without doubt, clinically we’re much better today. Also back then, there was hardly a consideration for atrocious racial disparities in care. We’ve not come far, but we are at least better off today than a few decades ago. And what about medicine as a profession? Although he had loads of autonomy and respect, Dr. Bellin also started every day of his 50-year career at 6 a.m. rounding in the newborn nursery before seeing patients in the office 6 days a week. Not many of us would trade our practice for his.
Yet, there’s reasons to be nostalgic. Chart notes might have been barely legible, but at least they served a purpose. The problem-oriented medical record was intended to logically capture and organize data. SOAP notes were invented to help us think better, to get diagnoses correct, to succinctly see progress. Today, notes are written for administrators and payers and patients. As a result, they’re often useless to us.
And although it may have been inconvenient to sit in the waiting room reading Highlights magazine, I’m unsure it was a worse user experience, compared with a chain pharmacy “virtual” doctor visit. (Particularly because you could always drop pennies down the large hot-air iron floor grate in the corner).
The thrumming undercurrent of progress promises artificial intelligence and genomics and wearable diagnostics in our future. But the assumption is the new things will be better suited to our needs than the old. Sometimes, they are not. Sometimes technology diminishes us instead of enhancing us.
I cannot count how many times I’ve hit my head or whacked my shin because our Tesla Model X doors open by magic and of their own accord. Back when I was young, we opened car doors by pulling on the door handle. I sometimes miss those days.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Use your court awareness to go faster in practice
Have you ever had a nightmare you’re running late? Recently I dreamt I was seeing patients on a ship, a little cruiser like the ones that give you tours of Boston Harbor, with low ceilings and narrow iron stairs. My nurse stood where what would have been the coffee and danish window. My first patient was a newborn (this was a nightmare, in case you forgot) who was enormous. She had a big belly and spindly legs that hung off the table. Uniform, umbilicated papules and pustules covered her body. At the sight of her, terror ripped through me – no clue. I rushed to the doctor lounge (nice the ship had one) and flipped channels on a little TV mounted on the ceiling. Suddenly, my nurse burst in, she was frantic because dozens of angry adults and crying children were crammed in the hallway. Apparently, I had been watching TV for hours and my whole clinic was now backed up.
Running-late dreams are common and usually relate to real life. For us, the clinic has been busy lately. Vaccinated patients are returning after a year with their skin cancers that have flourished and psoriasis covering them like kudzu. In particular, they “see the floor” better than other docs and therefore make continual adjustments to stay on pace. At its essence, they are using super-powers of observation to make decisions. It reminded me of a podcast about court awareness and great passers in basketball like the Charlotte Hornets’ LaMelo Ball and NBA great, Bill Bradley.
Bradley had an extraordinary ability to know where all the players were, and where they would be, at any given moment. He spent years honing this skill, noticing details in store windows as he stared straight ahead walking down a street. It’s reported his peripheral vision extended 5%-15% wider than average and he used it to gather more information and to process it more quickly. As a result he made outstanding decisions and fast, ultimately earning a spot in the Hall of Fame in Springfield.
[embed:render:related:node:237373]
Hall of Fame clinicians similarly take in a wider view than others and process that information quickly. They know how much time they have spent in the room, sense the emotional needs of the patient and anticipate the complexity of the problem. They quickly get to the critical questions and examinations that will make the diagnosis. They know the experience and skill of their medical assistant. They know the level of difficulty and even the temperament of patients who lie ahead on the schedule. All this is processed and used in moment-to-moment decision making. Do I sit down or stand up now? Can I excise this today, or reschedule? Do I ask another question? Do I step out of this room and see another in parallel while this biopsy is set up? And always, do I dare ask about grandkids or do I politely move on?
By broadening out their vision, they optimize their clinic, providing the best possible service, whether the day is busy or slow. I found their economy of motion also means they are less exhausted at the end of the day. I bet if when they dream of being on a ship, they’re sipping a Mai Tai, lounging on the deck.
For more on Bill Bradley and becoming more observant about your surroundings, you might appreciate the following:
www.newyorker.com/magazine/1965/01/23/a-sense-of-where-you-are and freakonomics.com/podcast/nsq-mindfulness/
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Have you ever had a nightmare you’re running late? Recently I dreamt I was seeing patients on a ship, a little cruiser like the ones that give you tours of Boston Harbor, with low ceilings and narrow iron stairs. My nurse stood where what would have been the coffee and danish window. My first patient was a newborn (this was a nightmare, in case you forgot) who was enormous. She had a big belly and spindly legs that hung off the table. Uniform, umbilicated papules and pustules covered her body. At the sight of her, terror ripped through me – no clue. I rushed to the doctor lounge (nice the ship had one) and flipped channels on a little TV mounted on the ceiling. Suddenly, my nurse burst in, she was frantic because dozens of angry adults and crying children were crammed in the hallway. Apparently, I had been watching TV for hours and my whole clinic was now backed up.
Running-late dreams are common and usually relate to real life. For us, the clinic has been busy lately. Vaccinated patients are returning after a year with their skin cancers that have flourished and psoriasis covering them like kudzu. In particular, they “see the floor” better than other docs and therefore make continual adjustments to stay on pace. At its essence, they are using super-powers of observation to make decisions. It reminded me of a podcast about court awareness and great passers in basketball like the Charlotte Hornets’ LaMelo Ball and NBA great, Bill Bradley.
Bradley had an extraordinary ability to know where all the players were, and where they would be, at any given moment. He spent years honing this skill, noticing details in store windows as he stared straight ahead walking down a street. It’s reported his peripheral vision extended 5%-15% wider than average and he used it to gather more information and to process it more quickly. As a result he made outstanding decisions and fast, ultimately earning a spot in the Hall of Fame in Springfield.
[embed:render:related:node:237373]
Hall of Fame clinicians similarly take in a wider view than others and process that information quickly. They know how much time they have spent in the room, sense the emotional needs of the patient and anticipate the complexity of the problem. They quickly get to the critical questions and examinations that will make the diagnosis. They know the experience and skill of their medical assistant. They know the level of difficulty and even the temperament of patients who lie ahead on the schedule. All this is processed and used in moment-to-moment decision making. Do I sit down or stand up now? Can I excise this today, or reschedule? Do I ask another question? Do I step out of this room and see another in parallel while this biopsy is set up? And always, do I dare ask about grandkids or do I politely move on?
By broadening out their vision, they optimize their clinic, providing the best possible service, whether the day is busy or slow. I found their economy of motion also means they are less exhausted at the end of the day. I bet if when they dream of being on a ship, they’re sipping a Mai Tai, lounging on the deck.
For more on Bill Bradley and becoming more observant about your surroundings, you might appreciate the following:
www.newyorker.com/magazine/1965/01/23/a-sense-of-where-you-are and freakonomics.com/podcast/nsq-mindfulness/
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Have you ever had a nightmare you’re running late? Recently I dreamt I was seeing patients on a ship, a little cruiser like the ones that give you tours of Boston Harbor, with low ceilings and narrow iron stairs. My nurse stood where what would have been the coffee and danish window. My first patient was a newborn (this was a nightmare, in case you forgot) who was enormous. She had a big belly and spindly legs that hung off the table. Uniform, umbilicated papules and pustules covered her body. At the sight of her, terror ripped through me – no clue. I rushed to the doctor lounge (nice the ship had one) and flipped channels on a little TV mounted on the ceiling. Suddenly, my nurse burst in, she was frantic because dozens of angry adults and crying children were crammed in the hallway. Apparently, I had been watching TV for hours and my whole clinic was now backed up.
Running-late dreams are common and usually relate to real life. For us, the clinic has been busy lately. Vaccinated patients are returning after a year with their skin cancers that have flourished and psoriasis covering them like kudzu. In particular, they “see the floor” better than other docs and therefore make continual adjustments to stay on pace. At its essence, they are using super-powers of observation to make decisions. It reminded me of a podcast about court awareness and great passers in basketball like the Charlotte Hornets’ LaMelo Ball and NBA great, Bill Bradley.
Bradley had an extraordinary ability to know where all the players were, and where they would be, at any given moment. He spent years honing this skill, noticing details in store windows as he stared straight ahead walking down a street. It’s reported his peripheral vision extended 5%-15% wider than average and he used it to gather more information and to process it more quickly. As a result he made outstanding decisions and fast, ultimately earning a spot in the Hall of Fame in Springfield.
[embed:render:related:node:237373]
Hall of Fame clinicians similarly take in a wider view than others and process that information quickly. They know how much time they have spent in the room, sense the emotional needs of the patient and anticipate the complexity of the problem. They quickly get to the critical questions and examinations that will make the diagnosis. They know the experience and skill of their medical assistant. They know the level of difficulty and even the temperament of patients who lie ahead on the schedule. All this is processed and used in moment-to-moment decision making. Do I sit down or stand up now? Can I excise this today, or reschedule? Do I ask another question? Do I step out of this room and see another in parallel while this biopsy is set up? And always, do I dare ask about grandkids or do I politely move on?
By broadening out their vision, they optimize their clinic, providing the best possible service, whether the day is busy or slow. I found their economy of motion also means they are less exhausted at the end of the day. I bet if when they dream of being on a ship, they’re sipping a Mai Tai, lounging on the deck.
For more on Bill Bradley and becoming more observant about your surroundings, you might appreciate the following:
www.newyorker.com/magazine/1965/01/23/a-sense-of-where-you-are and freakonomics.com/podcast/nsq-mindfulness/
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Say my name
Dr. Ben-a-bo?
Nope.
Ben-nabi?
Nope.
Ben-NO-bo?
Also no.
My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.
We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)
However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.
Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.
First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)
[embed:render:related:node:237373]
If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.
It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.
Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.
Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.
Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Dr. Ben-a-bo?
Nope.
Ben-nabi?
Nope.
Ben-NO-bo?
Also no.
My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.
We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)
However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.
Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.
First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)
[embed:render:related:node:237373]
If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.
It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.
Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.
Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.
Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Dr. Ben-a-bo?
Nope.
Ben-nabi?
Nope.
Ben-NO-bo?
Also no.
My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.
We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)
However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.
Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.
First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)
[embed:render:related:node:237373]
If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.
It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.
Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.
Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.
Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com
Applying lessons from Oprah to your practice
In my last column, I explained how I’m like Tom Brady. I’m not really. Brady is a Super Bowl–winning quarterback worth over $200 million. No, I’m like Oprah. Well, trying anyway.
Brady and Oprah, in addition to being gazillionaires, have in common that they’re arguably the GOATs (Greatest Of All Time) in their fields. Watching Oprah interview Meghan Markle and Prince Harry was like watching Tom Brady on the jumbotron – she made it look easy. Her ability to create conversation and coax information from guests is hall-of-fame good. But although they are both admirable, trying to be like Brady is useful only for next Thanksgiving when you’re trying to beat your cousins from Massachusetts in touch football. .
[embed:render:related:node:236069]
1. Prepare ahead. It’s clear that Oprah has binders of notes about her guests and thoroughly reviewed them before she invites them to sit down. We should do the same. Open the chart and read as much as you can before you open the door. Have important information in your head so you don’t have to break from your interview to refer to it.
2. Sprinkle pleasantry. She’d never start an interview with: So why are you here? Nor should we. Even one nonscripted question or comment can help build a little rapport before getting to the work.
3. Be brief. Oprah gets her question out fast, then gets out of the way. And as a bonus, this is the easiest place to shave a few minutes from your appointments from your own end. Think for a second before you speak and try to find the shortest route to your question. Try to keep your questions to just a sentence or two.
4. Stay on it. Once you’ve discovered something relevant, stay with it, resisting the urge to finish the review of symptoms. This is not just to make a diagnosis, but as importantly, trying to diagnose “the real reason” for the visit. Then, when the question is done, own the transition. Oprah uses: “Let’s move on.” This is a bit abrupt for us, but it can be helpful if used sparingly and gently. I might soften this a little by adding “I want to be sure we have enough time to get through everything for you.”
[embed:render:related:node:236069]
5. Wait. A few seconds seems an eternity on the air (and in clinic), but sometimes the silent pause is just what’s needed to help the patient expand and share.
6. Be nonjudgmental. Most of us believe we’re pretty good at this, yet, it’s sometimes a blind spot. It’s easy to blame the obese patient for his stasis dermatitis or the hidradenitis patient who hasn’t stop smoking for her cysts. It also helps to be nontransactional. If you make patients feel that you’re asking questions only to extract information, you’ll never reach Oprah level.
7. Be in the moment. It is difficult, but when possible, avoid typing notes while you’re still interviewing. We’re not just there to get the facts, we’re also trying to get the story and that sometimes takes really listening.
I’m no more like Oprah than Brady, of course. But it is more fun to close my eyes and imagine myself being her when I see my next patient. That is, until Thanksgiving. Watch out, Bedards from Attleboro.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
In my last column, I explained how I’m like Tom Brady. I’m not really. Brady is a Super Bowl–winning quarterback worth over $200 million. No, I’m like Oprah. Well, trying anyway.
Brady and Oprah, in addition to being gazillionaires, have in common that they’re arguably the GOATs (Greatest Of All Time) in their fields. Watching Oprah interview Meghan Markle and Prince Harry was like watching Tom Brady on the jumbotron – she made it look easy. Her ability to create conversation and coax information from guests is hall-of-fame good. But although they are both admirable, trying to be like Brady is useful only for next Thanksgiving when you’re trying to beat your cousins from Massachusetts in touch football. .
[embed:render:related:node:236069]
1. Prepare ahead. It’s clear that Oprah has binders of notes about her guests and thoroughly reviewed them before she invites them to sit down. We should do the same. Open the chart and read as much as you can before you open the door. Have important information in your head so you don’t have to break from your interview to refer to it.
2. Sprinkle pleasantry. She’d never start an interview with: So why are you here? Nor should we. Even one nonscripted question or comment can help build a little rapport before getting to the work.
3. Be brief. Oprah gets her question out fast, then gets out of the way. And as a bonus, this is the easiest place to shave a few minutes from your appointments from your own end. Think for a second before you speak and try to find the shortest route to your question. Try to keep your questions to just a sentence or two.
4. Stay on it. Once you’ve discovered something relevant, stay with it, resisting the urge to finish the review of symptoms. This is not just to make a diagnosis, but as importantly, trying to diagnose “the real reason” for the visit. Then, when the question is done, own the transition. Oprah uses: “Let’s move on.” This is a bit abrupt for us, but it can be helpful if used sparingly and gently. I might soften this a little by adding “I want to be sure we have enough time to get through everything for you.”
[embed:render:related:node:236069]
5. Wait. A few seconds seems an eternity on the air (and in clinic), but sometimes the silent pause is just what’s needed to help the patient expand and share.
6. Be nonjudgmental. Most of us believe we’re pretty good at this, yet, it’s sometimes a blind spot. It’s easy to blame the obese patient for his stasis dermatitis or the hidradenitis patient who hasn’t stop smoking for her cysts. It also helps to be nontransactional. If you make patients feel that you’re asking questions only to extract information, you’ll never reach Oprah level.
7. Be in the moment. It is difficult, but when possible, avoid typing notes while you’re still interviewing. We’re not just there to get the facts, we’re also trying to get the story and that sometimes takes really listening.
I’m no more like Oprah than Brady, of course. But it is more fun to close my eyes and imagine myself being her when I see my next patient. That is, until Thanksgiving. Watch out, Bedards from Attleboro.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
In my last column, I explained how I’m like Tom Brady. I’m not really. Brady is a Super Bowl–winning quarterback worth over $200 million. No, I’m like Oprah. Well, trying anyway.
Brady and Oprah, in addition to being gazillionaires, have in common that they’re arguably the GOATs (Greatest Of All Time) in their fields. Watching Oprah interview Meghan Markle and Prince Harry was like watching Tom Brady on the jumbotron – she made it look easy. Her ability to create conversation and coax information from guests is hall-of-fame good. But although they are both admirable, trying to be like Brady is useful only for next Thanksgiving when you’re trying to beat your cousins from Massachusetts in touch football. .
[embed:render:related:node:236069]
1. Prepare ahead. It’s clear that Oprah has binders of notes about her guests and thoroughly reviewed them before she invites them to sit down. We should do the same. Open the chart and read as much as you can before you open the door. Have important information in your head so you don’t have to break from your interview to refer to it.
2. Sprinkle pleasantry. She’d never start an interview with: So why are you here? Nor should we. Even one nonscripted question or comment can help build a little rapport before getting to the work.
3. Be brief. Oprah gets her question out fast, then gets out of the way. And as a bonus, this is the easiest place to shave a few minutes from your appointments from your own end. Think for a second before you speak and try to find the shortest route to your question. Try to keep your questions to just a sentence or two.
4. Stay on it. Once you’ve discovered something relevant, stay with it, resisting the urge to finish the review of symptoms. This is not just to make a diagnosis, but as importantly, trying to diagnose “the real reason” for the visit. Then, when the question is done, own the transition. Oprah uses: “Let’s move on.” This is a bit abrupt for us, but it can be helpful if used sparingly and gently. I might soften this a little by adding “I want to be sure we have enough time to get through everything for you.”
[embed:render:related:node:236069]
5. Wait. A few seconds seems an eternity on the air (and in clinic), but sometimes the silent pause is just what’s needed to help the patient expand and share.
6. Be nonjudgmental. Most of us believe we’re pretty good at this, yet, it’s sometimes a blind spot. It’s easy to blame the obese patient for his stasis dermatitis or the hidradenitis patient who hasn’t stop smoking for her cysts. It also helps to be nontransactional. If you make patients feel that you’re asking questions only to extract information, you’ll never reach Oprah level.
7. Be in the moment. It is difficult, but when possible, avoid typing notes while you’re still interviewing. We’re not just there to get the facts, we’re also trying to get the story and that sometimes takes really listening.
I’m no more like Oprah than Brady, of course. But it is more fun to close my eyes and imagine myself being her when I see my next patient. That is, until Thanksgiving. Watch out, Bedards from Attleboro.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
What Tom Brady and Patrick Mahomes can teach us about physicians
Warning: This article will be about Tom Brady. If you love Tom Brady, hate Tom Brady, previously loved and now hate Tom Brady, I’m just warning you so you’ll be in the right frame of mind to continue. (If you don’t know who Tom Brady is, he’s Gisele’s husband).
Brady, who plays for the Tampa Bay Buccaneers, has played in the NFL for 21 seasons, an unbelievable number given the average career for a quarterback is 3 years. He’s 43 years old and was the oldest player in a Super Bowl, ever. He faced Patrick Mahomes, the quarterback for the opposing Kansas City Chiefs. Mahomes is one of the most athletic and talented quarterbacks of all time, and Mahomes is nearly 20 years younger than Brady. Yet, in a shot heard around the NFL world, Brady won.
But, was a Brady victory so shocking? Hot-shot residents may have a lot of moxie and talent, but experienced doctors often prevail by simply making sound decisions and avoiding mistakes. In our department, we’ve been discussing this lately: We’re hiring two dermatologists and we’re fortunate to have some amazing candidates apply. Some, like Mahomes, are young all-stars with outstanding ability and potential, right out of residency. Others, Brady-like, have been in practice for years and are ready to move to a new franchise.
Our medical group’s experiences are probably similar to many practices: New physicians out of residency often bring energy, inspiration, and ease with the latest therapies, devices, and surgical techniques. Yet, they sometimes struggle with efficiency and unforced errors. Experienced physicians might not know what’s hot, but they can often see where the best course of action lies, understanding not only the physiology but also the patient in ways that only experience can teach you. Fortunately, for those like me who’ve crossed midlife, there doesn’t seem to be an upper limit to experience – it is possible to keep getting better. Yes, I’m just like Tom Brady. (I wrote this article just to print that line.)
[embed:render:related:node:208429]
Some of the best doctors I’ve ever seen in action were emeritus physicians. In medical school at Wake Forest University, one of my professors was Dr. Eben Alexander. A retired neurosurgeon, he taught a case-based critical thinking skills class. I recall his brilliant insight and coaching, working through cases that had nothing to do with the brain or with surgery. He used his vast experience and wisdom to teach us how to practice medicine. He was, at that time, nearly 90 years old. Despite having been retired for decades, he was still writing articles and editing journals. He was inspiring. For a minute, he had me thinking I’d like to be a neurosurgeon, so I could be just like Eben Alexander. I did not, but I learned things from him that still impact my practice as a dermatologist today.
I’m sure you’ve had similar experiences of older colleagues or mentors who were the best doctor in the clinic or the O.R. They are the Dr. Anthony Faucis, not just practicing, but leading while in their 8th or 9th decade. We are all so fortunate that they keep playing.
We’ve not made our final choices on whom to hire, but with two positions, I expect we’ll choose both a young doctor and an experienced one to add to our team. It will be fun to watch and learn from them. Just like it will be fun to watch Tom Brady in the Super Bowl again next year.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Warning: This article will be about Tom Brady. If you love Tom Brady, hate Tom Brady, previously loved and now hate Tom Brady, I’m just warning you so you’ll be in the right frame of mind to continue. (If you don’t know who Tom Brady is, he’s Gisele’s husband).
Brady, who plays for the Tampa Bay Buccaneers, has played in the NFL for 21 seasons, an unbelievable number given the average career for a quarterback is 3 years. He’s 43 years old and was the oldest player in a Super Bowl, ever. He faced Patrick Mahomes, the quarterback for the opposing Kansas City Chiefs. Mahomes is one of the most athletic and talented quarterbacks of all time, and Mahomes is nearly 20 years younger than Brady. Yet, in a shot heard around the NFL world, Brady won.
But, was a Brady victory so shocking? Hot-shot residents may have a lot of moxie and talent, but experienced doctors often prevail by simply making sound decisions and avoiding mistakes. In our department, we’ve been discussing this lately: We’re hiring two dermatologists and we’re fortunate to have some amazing candidates apply. Some, like Mahomes, are young all-stars with outstanding ability and potential, right out of residency. Others, Brady-like, have been in practice for years and are ready to move to a new franchise.
Our medical group’s experiences are probably similar to many practices: New physicians out of residency often bring energy, inspiration, and ease with the latest therapies, devices, and surgical techniques. Yet, they sometimes struggle with efficiency and unforced errors. Experienced physicians might not know what’s hot, but they can often see where the best course of action lies, understanding not only the physiology but also the patient in ways that only experience can teach you. Fortunately, for those like me who’ve crossed midlife, there doesn’t seem to be an upper limit to experience – it is possible to keep getting better. Yes, I’m just like Tom Brady. (I wrote this article just to print that line.)
[embed:render:related:node:208429]
Some of the best doctors I’ve ever seen in action were emeritus physicians. In medical school at Wake Forest University, one of my professors was Dr. Eben Alexander. A retired neurosurgeon, he taught a case-based critical thinking skills class. I recall his brilliant insight and coaching, working through cases that had nothing to do with the brain or with surgery. He used his vast experience and wisdom to teach us how to practice medicine. He was, at that time, nearly 90 years old. Despite having been retired for decades, he was still writing articles and editing journals. He was inspiring. For a minute, he had me thinking I’d like to be a neurosurgeon, so I could be just like Eben Alexander. I did not, but I learned things from him that still impact my practice as a dermatologist today.
I’m sure you’ve had similar experiences of older colleagues or mentors who were the best doctor in the clinic or the O.R. They are the Dr. Anthony Faucis, not just practicing, but leading while in their 8th or 9th decade. We are all so fortunate that they keep playing.
We’ve not made our final choices on whom to hire, but with two positions, I expect we’ll choose both a young doctor and an experienced one to add to our team. It will be fun to watch and learn from them. Just like it will be fun to watch Tom Brady in the Super Bowl again next year.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
Warning: This article will be about Tom Brady. If you love Tom Brady, hate Tom Brady, previously loved and now hate Tom Brady, I’m just warning you so you’ll be in the right frame of mind to continue. (If you don’t know who Tom Brady is, he’s Gisele’s husband).
Brady, who plays for the Tampa Bay Buccaneers, has played in the NFL for 21 seasons, an unbelievable number given the average career for a quarterback is 3 years. He’s 43 years old and was the oldest player in a Super Bowl, ever. He faced Patrick Mahomes, the quarterback for the opposing Kansas City Chiefs. Mahomes is one of the most athletic and talented quarterbacks of all time, and Mahomes is nearly 20 years younger than Brady. Yet, in a shot heard around the NFL world, Brady won.
But, was a Brady victory so shocking? Hot-shot residents may have a lot of moxie and talent, but experienced doctors often prevail by simply making sound decisions and avoiding mistakes. In our department, we’ve been discussing this lately: We’re hiring two dermatologists and we’re fortunate to have some amazing candidates apply. Some, like Mahomes, are young all-stars with outstanding ability and potential, right out of residency. Others, Brady-like, have been in practice for years and are ready to move to a new franchise.
Our medical group’s experiences are probably similar to many practices: New physicians out of residency often bring energy, inspiration, and ease with the latest therapies, devices, and surgical techniques. Yet, they sometimes struggle with efficiency and unforced errors. Experienced physicians might not know what’s hot, but they can often see where the best course of action lies, understanding not only the physiology but also the patient in ways that only experience can teach you. Fortunately, for those like me who’ve crossed midlife, there doesn’t seem to be an upper limit to experience – it is possible to keep getting better. Yes, I’m just like Tom Brady. (I wrote this article just to print that line.)
[embed:render:related:node:208429]
Some of the best doctors I’ve ever seen in action were emeritus physicians. In medical school at Wake Forest University, one of my professors was Dr. Eben Alexander. A retired neurosurgeon, he taught a case-based critical thinking skills class. I recall his brilliant insight and coaching, working through cases that had nothing to do with the brain or with surgery. He used his vast experience and wisdom to teach us how to practice medicine. He was, at that time, nearly 90 years old. Despite having been retired for decades, he was still writing articles and editing journals. He was inspiring. For a minute, he had me thinking I’d like to be a neurosurgeon, so I could be just like Eben Alexander. I did not, but I learned things from him that still impact my practice as a dermatologist today.
I’m sure you’ve had similar experiences of older colleagues or mentors who were the best doctor in the clinic or the O.R. They are the Dr. Anthony Faucis, not just practicing, but leading while in their 8th or 9th decade. We are all so fortunate that they keep playing.
We’ve not made our final choices on whom to hire, but with two positions, I expect we’ll choose both a young doctor and an experienced one to add to our team. It will be fun to watch and learn from them. Just like it will be fun to watch Tom Brady in the Super Bowl again next year.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
An introduction to Naikan
The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.
Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.
It’s a Japanese method called Naikan (pronounced “nye-kan”). The word means introspection and the practice is one of self-reflection. But . Yoshimoto Ishin developed Naikan in the 1940s. He was a Japanese businessman and devout Buddhist who wanted to make a difficult form of meditation more accessible. He removed the ascetic bits like sleep deprivation and refined the exercises such that they better see how others see us. The result is a way to reframe your life experiences and help you understand how much others do for us and how our actions and attitudes impact others. It can be done alone or with a partner. You can do it at the beginning or end of your day.
The method is simple. You ask three questions:
What have I received today from ___________?
What have I given today to ___________?
What difficulty or trouble have I caused to ___________?
The first question is similar to most gratitude practices. For example, you might ask, “What have I received from (my husband or nurse or friend, etc.)? Today, I received a beautifully tidied-up office from my wife who spent time last night sorting things. This made it easy for me to sit down and start writing this piece.
The second question is better. What have I given today to (my wife, or patient, or mom, etc.)? It can be simple as: Today, I slowed down to let everyone who was in the closed highway lane back into traffic (even though some were clearly undeserving of my generosity). Or last night, I worked to coordinate with anesthesia and scheduling to help a little girl who would benefit from conscious sedation for her procedure.
Combined, these two questions pull you 180 degrees from our default mode, which is complaining. We are wired to find, and talk about, all the inconveniences in our lives: Roadway construction caused a traffic backup that led to running late for clinic. First patient was peeved and had a list of complaints, the last of which was hair loss. Isn’t it much better to rave about how our dermatology nurse volunteered to work the hospital COVID-19 unit to give her colleagues a break? Or how my 10:15 patient came early to be sure she was on time? (It happens.)
[embed:render:related:node:221085]
The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.
There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.
If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com .
The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.
Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.
It’s a Japanese method called Naikan (pronounced “nye-kan”). The word means introspection and the practice is one of self-reflection. But . Yoshimoto Ishin developed Naikan in the 1940s. He was a Japanese businessman and devout Buddhist who wanted to make a difficult form of meditation more accessible. He removed the ascetic bits like sleep deprivation and refined the exercises such that they better see how others see us. The result is a way to reframe your life experiences and help you understand how much others do for us and how our actions and attitudes impact others. It can be done alone or with a partner. You can do it at the beginning or end of your day.
The method is simple. You ask three questions:
What have I received today from ___________?
What have I given today to ___________?
What difficulty or trouble have I caused to ___________?
The first question is similar to most gratitude practices. For example, you might ask, “What have I received from (my husband or nurse or friend, etc.)? Today, I received a beautifully tidied-up office from my wife who spent time last night sorting things. This made it easy for me to sit down and start writing this piece.
The second question is better. What have I given today to (my wife, or patient, or mom, etc.)? It can be simple as: Today, I slowed down to let everyone who was in the closed highway lane back into traffic (even though some were clearly undeserving of my generosity). Or last night, I worked to coordinate with anesthesia and scheduling to help a little girl who would benefit from conscious sedation for her procedure.
Combined, these two questions pull you 180 degrees from our default mode, which is complaining. We are wired to find, and talk about, all the inconveniences in our lives: Roadway construction caused a traffic backup that led to running late for clinic. First patient was peeved and had a list of complaints, the last of which was hair loss. Isn’t it much better to rave about how our dermatology nurse volunteered to work the hospital COVID-19 unit to give her colleagues a break? Or how my 10:15 patient came early to be sure she was on time? (It happens.)
[embed:render:related:node:221085]
The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.
There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.
If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com .
The list of things to be ungrateful for last year is long. You’re not supposed to make this list, though. The best practice is to list what you’re grateful for, even when living in trying times. That’s a long list too, but I find making it similarly unfruitful.
Of course, I’m grateful I don’t have COVID-19, thankful my practice hasn’t been significantly impacted, grateful I got the vaccine. But simply repeating these gratitudes daily seems ineffective. I’ve learned a different “gratefulness practice” that perhaps works better.
It’s a Japanese method called Naikan (pronounced “nye-kan”). The word means introspection and the practice is one of self-reflection. But . Yoshimoto Ishin developed Naikan in the 1940s. He was a Japanese businessman and devout Buddhist who wanted to make a difficult form of meditation more accessible. He removed the ascetic bits like sleep deprivation and refined the exercises such that they better see how others see us. The result is a way to reframe your life experiences and help you understand how much others do for us and how our actions and attitudes impact others. It can be done alone or with a partner. You can do it at the beginning or end of your day.
The method is simple. You ask three questions:
What have I received today from ___________?
What have I given today to ___________?
What difficulty or trouble have I caused to ___________?
The first question is similar to most gratitude practices. For example, you might ask, “What have I received from (my husband or nurse or friend, etc.)? Today, I received a beautifully tidied-up office from my wife who spent time last night sorting things. This made it easy for me to sit down and start writing this piece.
The second question is better. What have I given today to (my wife, or patient, or mom, etc.)? It can be simple as: Today, I slowed down to let everyone who was in the closed highway lane back into traffic (even though some were clearly undeserving of my generosity). Or last night, I worked to coordinate with anesthesia and scheduling to help a little girl who would benefit from conscious sedation for her procedure.
Combined, these two questions pull you 180 degrees from our default mode, which is complaining. We are wired to find, and talk about, all the inconveniences in our lives: Roadway construction caused a traffic backup that led to running late for clinic. First patient was peeved and had a list of complaints, the last of which was hair loss. Isn’t it much better to rave about how our dermatology nurse volunteered to work the hospital COVID-19 unit to give her colleagues a break? Or how my 10:15 patient came early to be sure she was on time? (It happens.)
[embed:render:related:node:221085]
The last question is the best. We all spend time thinking about what others think of us. We should spend time thinking about what impact we’ve had on them. Like a cold shower, it’s both briskly awakening and easy to do. Go back through your day and reflect on what you did that made things difficult for others. It can be as simple as I started whining about how a patient waylaid me with her silly complaints. That led to my colleague’s joining in about difficult patients. Or I was late turning in my article, which made my editor have to work harder to get it completed in time.
There’s plenty of things we should be grateful for. In doing these exercises you’ll learn just how much others have cared for you and, I hope, how you might do things to make them grateful for you.
If you’re interested in learning more about Naikan, I discovered this from Brett McKay’s The Art of Manliness podcast and the teaching of Gregg Krech, summarized in his book, “Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection.”
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com .
Practicing medicine without judgment
“What do you think of all this election stuff?” I froze. Sitting on the exam table was a 50-something-year-old woman. Her hair was long, but not gray. She was wearing a mask without distinctive markings, such as Trump lips or #BLM to identify the political leanings of the owner. She had a subtle New York accent, perhaps dating back to the Giuliani years. It was hard to know her intention. “It’s a trap!” I could hear Admiral Ackbar’s voice in my head. “Don’t engage.” We all know nothing erodes trust faster than showing your blue or red colors before you know which your patient identifies.
Instead, I replied that indeed it has been a stressful year for us all. Then I paused. She shifted a bit and tugged at the gown sleeves and admitted this was the most stress she felt in years. She was seeing me for lichen sclerosus et atrophicus, a terribly itchy, sometimes-disfiguring eruption that can occur in the vulva. She was dealing with COVID-19, kids, divorce, a new partner, working from home, parents, and now the election drama.
At this point in the visit, I knew I could help her. First, the treatment for lichen sclerosus is straightforward and mostly effective. Second, I knew I’d have 7 minutes to spare to just listen. It was a lucky break, as often no such gift of time presents itself while seeing patients in a busy clinic. We take vitals, history (typing), do an exam, make a diagnosis (more typing), and maybe a procedure (yet more typing). All of this is necessary, but sometimes not what our patient needs. Some really need just to connect and share their burden with someone who isn’t a friend or family. As physicians, we have a unique opportunity to see and hear people without judgment.
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This reminds me of a recent episode from Sam Harris’s podcast, “Making Sense.” Mr. Harris, a philosopher (and “blue” all the way through) revealed his insight into Presidents Trump’s appeal. Leaving policy aside, Mr. Harris notes that people are drawn to the President because he never judges you. He is incapable of being sanctimonious, Mr. Harris argues, and therefore creates a safe space for people to continue their lives, however flawed, without expectation that they improve.
I’m unsure just how much of this theory explains the devotion of his supporters, but it resonated with me. We doctors are sanctimonious by nature. The better part of my day is spent prodding people to be better: Wear more sunscreen, exercise more, stop believing in conspiracy theories, get your flu shot, and above all, stop scratching! In doing so, I’m in a way judging them. Finger wagging: You’re lazy or poor or dumb or stubborn. “You aren’t as good as me,” is what they might feel after 15 minutes of my pep talk.
But what if that’s wrong? What if they are just fine exactly the way they are? Perhaps what my lichen sclerosis patient needs more than anything is unconditional attention? She, like most of our patients, is well aware of how her shortcomings might contribute to her own anxiety or difficulties. And now she has this rash and that’s probably somehow her fault too, she thinks.
How can I best help her? Betamethasone dipropionate b.i.d. for 2 weeks and spend the last 7 minutes just sitting and listening without judgment or advice. I don’t know who she wanted to win the election. It didn’t matter, she was exactly right to believe what she believed, either way.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
“What do you think of all this election stuff?” I froze. Sitting on the exam table was a 50-something-year-old woman. Her hair was long, but not gray. She was wearing a mask without distinctive markings, such as Trump lips or #BLM to identify the political leanings of the owner. She had a subtle New York accent, perhaps dating back to the Giuliani years. It was hard to know her intention. “It’s a trap!” I could hear Admiral Ackbar’s voice in my head. “Don’t engage.” We all know nothing erodes trust faster than showing your blue or red colors before you know which your patient identifies.
Instead, I replied that indeed it has been a stressful year for us all. Then I paused. She shifted a bit and tugged at the gown sleeves and admitted this was the most stress she felt in years. She was seeing me for lichen sclerosus et atrophicus, a terribly itchy, sometimes-disfiguring eruption that can occur in the vulva. She was dealing with COVID-19, kids, divorce, a new partner, working from home, parents, and now the election drama.
At this point in the visit, I knew I could help her. First, the treatment for lichen sclerosus is straightforward and mostly effective. Second, I knew I’d have 7 minutes to spare to just listen. It was a lucky break, as often no such gift of time presents itself while seeing patients in a busy clinic. We take vitals, history (typing), do an exam, make a diagnosis (more typing), and maybe a procedure (yet more typing). All of this is necessary, but sometimes not what our patient needs. Some really need just to connect and share their burden with someone who isn’t a friend or family. As physicians, we have a unique opportunity to see and hear people without judgment.
[embed:render:related:node:228680]
This reminds me of a recent episode from Sam Harris’s podcast, “Making Sense.” Mr. Harris, a philosopher (and “blue” all the way through) revealed his insight into Presidents Trump’s appeal. Leaving policy aside, Mr. Harris notes that people are drawn to the President because he never judges you. He is incapable of being sanctimonious, Mr. Harris argues, and therefore creates a safe space for people to continue their lives, however flawed, without expectation that they improve.
I’m unsure just how much of this theory explains the devotion of his supporters, but it resonated with me. We doctors are sanctimonious by nature. The better part of my day is spent prodding people to be better: Wear more sunscreen, exercise more, stop believing in conspiracy theories, get your flu shot, and above all, stop scratching! In doing so, I’m in a way judging them. Finger wagging: You’re lazy or poor or dumb or stubborn. “You aren’t as good as me,” is what they might feel after 15 minutes of my pep talk.
But what if that’s wrong? What if they are just fine exactly the way they are? Perhaps what my lichen sclerosis patient needs more than anything is unconditional attention? She, like most of our patients, is well aware of how her shortcomings might contribute to her own anxiety or difficulties. And now she has this rash and that’s probably somehow her fault too, she thinks.
How can I best help her? Betamethasone dipropionate b.i.d. for 2 weeks and spend the last 7 minutes just sitting and listening without judgment or advice. I don’t know who she wanted to win the election. It didn’t matter, she was exactly right to believe what she believed, either way.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.
“What do you think of all this election stuff?” I froze. Sitting on the exam table was a 50-something-year-old woman. Her hair was long, but not gray. She was wearing a mask without distinctive markings, such as Trump lips or #BLM to identify the political leanings of the owner. She had a subtle New York accent, perhaps dating back to the Giuliani years. It was hard to know her intention. “It’s a trap!” I could hear Admiral Ackbar’s voice in my head. “Don’t engage.” We all know nothing erodes trust faster than showing your blue or red colors before you know which your patient identifies.
Instead, I replied that indeed it has been a stressful year for us all. Then I paused. She shifted a bit and tugged at the gown sleeves and admitted this was the most stress she felt in years. She was seeing me for lichen sclerosus et atrophicus, a terribly itchy, sometimes-disfiguring eruption that can occur in the vulva. She was dealing with COVID-19, kids, divorce, a new partner, working from home, parents, and now the election drama.
At this point in the visit, I knew I could help her. First, the treatment for lichen sclerosus is straightforward and mostly effective. Second, I knew I’d have 7 minutes to spare to just listen. It was a lucky break, as often no such gift of time presents itself while seeing patients in a busy clinic. We take vitals, history (typing), do an exam, make a diagnosis (more typing), and maybe a procedure (yet more typing). All of this is necessary, but sometimes not what our patient needs. Some really need just to connect and share their burden with someone who isn’t a friend or family. As physicians, we have a unique opportunity to see and hear people without judgment.
[embed:render:related:node:228680]
This reminds me of a recent episode from Sam Harris’s podcast, “Making Sense.” Mr. Harris, a philosopher (and “blue” all the way through) revealed his insight into Presidents Trump’s appeal. Leaving policy aside, Mr. Harris notes that people are drawn to the President because he never judges you. He is incapable of being sanctimonious, Mr. Harris argues, and therefore creates a safe space for people to continue their lives, however flawed, without expectation that they improve.
I’m unsure just how much of this theory explains the devotion of his supporters, but it resonated with me. We doctors are sanctimonious by nature. The better part of my day is spent prodding people to be better: Wear more sunscreen, exercise more, stop believing in conspiracy theories, get your flu shot, and above all, stop scratching! In doing so, I’m in a way judging them. Finger wagging: You’re lazy or poor or dumb or stubborn. “You aren’t as good as me,” is what they might feel after 15 minutes of my pep talk.
But what if that’s wrong? What if they are just fine exactly the way they are? Perhaps what my lichen sclerosis patient needs more than anything is unconditional attention? She, like most of our patients, is well aware of how her shortcomings might contribute to her own anxiety or difficulties. And now she has this rash and that’s probably somehow her fault too, she thinks.
How can I best help her? Betamethasone dipropionate b.i.d. for 2 weeks and spend the last 7 minutes just sitting and listening without judgment or advice. I don’t know who she wanted to win the election. It didn’t matter, she was exactly right to believe what she believed, either way.
Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.