The Power of Good News

Recently, I had the opportunity to see a young boy in my clinic, a great little guy who had had a bit of a rocky start to life. He had been born four months premature, and had sustained an intraventricular hemorrhage, a type of bleeding within the brain that is, unfortunately, quite common in severely premature infants. To reduce the swelling and pressure in his head created by this bleeding, a shunt was placed, which drained fluid from around the brain into his abdomen.

Between this brain hemorrhage and a number of other medical problems, my little patient's first few years were tough. His mother had been told that, because of the swelling, he had likely suffered some damage to his optic nerves, the structures that connect the back of the eye to the brain, and transmit the signal that the eye sees to the cerebral cortex for processing.

Fortunately, when I examined his eyes, I was able to get a good look at his optic nerves, and they appeared very healthy -- flat and pink, just like they should be, with no swelling, pallor, or hemorrhage. I told Mom that her son's optic nerves looked great, and that I was encouraged by that. Her response caught me off guard.

She said, somberly but matter-of-factly, "That's great. We never get good news."

This made me feel very sad.

One of the blessings of my job is that I work with kids all day -- kids who are often, though not always, generally quite healthy. This means that my experience in the "doctor's office" (in this case, my own), is usually very positive and full of good news.

This young family, by contrast -- and many others like them -- has a much different typical doctor's office experience. Because of the many, severe health problems their son has dealt with, his physicians have, unfortunately but appropriately, had to give an awful lot of bad news.

Sometimes as physicians, we may forget how devastating a seemingly endless parade of bad news can be.

My friend Dr. Erin Schotthoefer, a fellow pediatric ophthalmologist who also did her ophthalmology residency at the University of Iowa like I did, taught me something very profound. During a lecture given 10 years after finishing her training, she told the audience that, for every patient she saw, she always tried to find at least one bit of good news she could share, one thing about which the child's parents should be happy and encouraged.

Inspired by her words, I have tried to do the same in my practice, and have found it both possible and powerful. Sometimes, we all just need something to hold on to, and findings those things and sharing them is one of my favorite parts of what I do.

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How to Be Successful When on Call

I was on call over Christmas here in Spokane, and it was fairly busy. Not as busy as it would be for some other specialties, but still busy. For 96 straight hours, I was the ophthalmologist covering all consults for three hospitals in the city, and I was also on call for the patients in our call group, which consists of about 25 ophthalmologists. 

For the past eight years, I've had the opportunity to be on call hundreds of times. It's not my favorite part of my job -- and I'm not sure it is for anyone! -- but I've found a few tips that have helped me be successful on call:

1. Manage your expectations. If you assume you won't be busy, at best you will be satisfied, and more than likely you will be disappointed. By contrast, if you prepare for nonstop action, you will be pleasantly surprised and grateful if you get some sleep or time to sit down.

2. Be efficient. Focus on the "W-I-N" strategy: what's important now? What do you need to do to save this person's life/limb/vision until the morning? Don't get bogged down.

3. Most importantly: Remember, you signed up for this. Your patient did not. He or she is seeing you at one of the most vulnerable times in their life. They need your help.

When I posted this on my Facebook page, Dr. Tom Oetting, a great mentor and friend, had the following to say:

People are scared and often just need reassurance. Took me a long time (and having kids) to figure out just how anxious we as parents can get. . . Even though some of the things we see on call seem trivial to us they can really jazz up a family unit! So we shouldn't be surprised or resentful if some of our on call activity seems trivial.

Another friend, the retina surgeon Dr. Jayanth Sridhar, whose new podcast can be heard here, recommend the following:

Keep snacks in your bag. Something quick may end up being longer than you think. Always carry a phone charger.

What do you think? What tips for success on call have you found? Have you had any experience with on-call physicians that were particularly memorable? Comment below!

Being Fast

It was a hot, sunny summer afternoon, and we were all excited for high school graduation the next day. As was our habit, after school got out, my friends and I went over to a neighbor's house to play basketball on their beautiful outdoor full court, complete with painted lines and breakaway rims, just like the pros used. I grabbed a rebound, dribbled the length of the court, and went up for a dunk. I vividly recall being in midair, the defender underneath/in front of me, and realizing my body was now parallel to the ground and bad things were about to happen. I landed awkwardly on my arm, figured it was broken, and went to the emergency room with my mother.

Dr. Swensen, recipient of the Utah State Orthopaedic Society's 2013 Sherman S. Coleman Humanitarian Award.

Mom asked for Dr. Laird Swensen, a hand surgeon who had taken care of my family in the past. Dr. Swensen, a tall, kind, soft-spoken 50-something-year-old, graciously rearranged his schedule to come see me. My wrist was indeed broken, and Dr. Swensen set the fracture and put on a cast. A few weeks later, when X-rays revealed the fracture wasn't healing perfectly, Dr. Swensen recommended surgery. Nervous that I would never be able to play basketball again (18-year-olds have a different version of what's important), I called him the night before surgery. He reassured me. The surgery went great, and my wrist has been as good as new ever since. Dr. Swensen became a hero of mine.

A few years later, I had the opportunity to work as an orderly in the operating rooms where Dr. Swensen and other orthopedists operated. I took patients to and from surgery and helped prepare and clean the operating rooms. Early on, while chatting with one of the surgical technicians, I mentioned how highly I thought of Dr. Swensen. My coworker shrugged and said, "He's so slow."

This comment caught me completely off guard. Slow? What does that mean? Who cares if he's slow? Why is that even a thing? Isn't the only thing that matters whether he's "good" or not? Perhaps my colleague was just accustomed to other orthopedic surgeries, which are often much quicker, and not to hand/wrist surgery, which, due to the intricate anatomy, is meticulous and often drawn-out. But I was still miffed that the first adjective used to describe this excellent surgeon was the word "slow."

Since that time, I have on occasion noticed that a slow surgeon can be an annoyance to others that work in an operating room -- including nurses, technicians, anesthesiologists, etc. -- because of how long their cases take. Also, from a patient safety standpoint, all other things being equal, the less time spent under anesthesia, the better, and from a business standpoint, the quicker a procedure is, the more time available for other patients and procedures. And slow doesn't automatically equate with good. I understand all of that. Maybe I was naive, but I just never imagined that a physician's speed would have any bearing on what colleagues thought of him or her.

This pressure, to be not only excellent but also efficient, is something that every surgeon and every physician faces. Clearly, the ideal is that care is both excellent and efficient, 100% of the time. That's what's best for patients. In most cases, it's possible. But sometimes things aren't straightforward; surprises happen in the operating room or in the clinic, and when that happens, it's crucial that speed take a back seat to quality. I believe it's important to strive for perfection, not just "good enough."

My favorite anecdote regarding this issue comes from a surgeon I know who, during a meeting with his boss, was made aware that he took longer to do a given type of surgery than his colleagues did. The surgeon -- accurately, by the way -- replied, "Yeah. But mine work." That surgeon understood that while time is of the essence in the operating room for many reasons, the most critical aspect of the case is that it's done well, not that it's done quickly.

Every time I enter the operating room, I think about that surgeon, and about Dr. Swensen. I am so fortunate to have trained at the University of Iowa and to work at the Spokane Eye Clinic with colleagues that share this same approach.

What do you think? Have you faced pressure to be both good and fast in your career? How have you handled that? Comments welcome!