The New Language of Medicine

In the October 13, 2011 New England Journal of Medicine there is a Perspective article entitled “The New Language of Medicine.” The authors assess the recent use of the terms “consumer”, “customer,” and “provider.” I urge all physicians to read this very well done essay that we are republishing in the print edition of the December issue of Minnesota Medicine.

Lyle Swenson, M.D.,
2011-2012 MMA President

The article states the importance of the words we use to explain our roles, and how they “set expectations and shape behavior.” While many in the health care industry may try to justify the use of the term provider, this is an all-purpose term that is “deliberately and strikingly generic, designating no specific role or level of expertise.”  It does not begin to capture the complex, and tremendously important role physicians have, and carries no implication of professionalism.

The generic term “provider” suggests that doctors and other health care professionals are interchangeable. The authors state that use of the term “provider” signals that care is a prepackaged commodity that is “provided” to the “consumer,” rather than a personalized service delivered by skilled professionals, tailored to the needs of the individual patient. They conclude that reducing the relationship between physicians and patients to a commercial transaction of buyer and seller ignores the essential psychological, spiritual, and humanistic dimensions of the relationship, which are essential to our profession.

We must take on the responsibility for how our profession is defined. This is a beautiful, clear, and concise discussion of why physicians must reject use of the term provider for our own profession.

Our core principles

Lyle Swenson, M.D.,
2011-2012 MMA President

It was a great honor to be inaugurated MMA President on September 15. Afterwards, I even had a few requests for the text of my speech. So though it is long for a blog post, I wanted to include it here, since it addresses some of the key issues I hope to focus on as MMA President. 

Inaugural Address

 Our profession has its origins in antiquity.  The earliest known written records of mankind are found on Sumerian clay tablets from Mesopotamia, which are over 4000 years old.  These tablets contain the oldest medical manuscripts, and they give us some insight into the role of the asu, the physician, in this ancient society.

     From the Code of King Hammurabi, 1700 years before the birth of Christ, we find a detailed description of the rewards due to the surgeon for surgical procedures prevalent during that time.

     The foundations of our profession were most firmly established by Hippocrates, the Greek physician we call the Father of Medicine.  In his oath, we find the enduring principles that have guided us as physicians for over 2000 years. In the Hippocratic oath, and in the oaths now taken by all those who become physicians, we find the basis for the relationship that we have with our patients.  This commitment is a covenant, which is an agreement based on trust.  In our oath we also pledge to hold the health, well-being, and best interests of our patients above all else, and above our own interests.  We pledge to do no harm to our patients, and to hold all that passes between our patients and ourselves in confidence, in order to protect our patients, and to maintain their trust.

     In the second century after Christ, scientific medical investigation by Galen led to the realization that   anatomic accuracy and physiology are the basis for the understanding of disease. 1000 years later, the scholar, philosopher, scientist, and physician Maimonides further defined and shaped our profession.  In his physician’s prayer, Maimonides writes “Inspire me with love for my art and for Thy creatures.  Do not allow thirst for profit, nor ambition for renown, to interfere with my profession”.  As Dr. Carmel has so eloquently stated, this is what we call integrity. He has also reminded us that in the care of our patients, we must have compassion, we must have empathy.  The traditions of using scientific knowledge for the benefit of our patients, with integrity and empathy, have been growing for thousands of years.

     From the earliest efforts of the asu, to the scientific investigations of Galen, to the discovery of the double helix by Watson and Crick, our profession has seen profound changes in our ability to understand, diagnose, treat, and cure disease. With the tremendous growth in scientific knowledge and our improved understanding of disease, there have been great opportunities to improve the health of our patients.  With these opportunities have come great challenges, and the challenges of our time now threaten the very foundation and time-honored principles of our profession.
    
 With greater scientific knowledge has come the need and the desire for specialization, and the development of medical subspecialties has given us the potential for better care for our patients, but it has also led to disagreements between specialty societies and a lack of unity  within our profession.

     With the commercialization of health care, the potential for financial gain has led to worrisome conflicts with the principles of our profession. The business of health care has become politicized, and now political posturing and ideology threaten to drive us apart as physicians.

     Fundamental changes in the delivery and financing of health care have resulted in the rewards to our profession being doled out by large payers who are influenced primarily by economics and politics, with those rewards having little relationship to the value we bring to our patients and our communities.  Many physicians have understandably responded to these realities by changing their medical practice, and some of these changes have resulted in alliances and relationships which challenge, and threaten to alter, the covenant we have with our patients.  The conflict between economic survival and prosperity on the one hand, and the best interest of our patients on the other, is certainly not new, but our current conflict is unprecedented in its magnitude, and how we, as a profession, respond to this conflict will have profound effects lasting many, many years.

     As we recall the history of medicine, we recognize and cherish the abiding principles that give us hope and guidance in our professional lives today.  The supreme importance of our patients’ health and wellbeing; the covenant we have with each patient we care for; the continual quest to bring new scientific knowledge into our practice for the benefit of our patients, brought with integrity, trust, empathy, and compassion; these principles we must hold sacred.

     All challenges to our profession, whether great or small, must be faced openly and honestly, with courage, without restraint or hesitation, and without deference to politics, ideology, or commercial interest. We must renew our commitment to our profession.  We must renew our commitment to the principles of our profession.  We must be unwavering in their support, and we must resist the forces that threaten to drive us apart.

     It is now our time to do our part, as physicians have done for thousands of years, so that in the years to come, physicians will be free to practice the science and the art of medicine, with knowledge, integrity, empathy, and compassion, for the benefit of their patients.

To Err is Human



Patricia Lindholm, MD,
2010-2011 MMA President



I believe that we all recognize the above title as a timeless adage, but also the title of the Institute of Medicine report that brought to public scrutiny the problem of medical errors in hospitals and the prevalence of harm that patients experience during their hospitalizations.  The report jump-started a nascent patient safety movement that now appropriately applies to outpatient care as well. 

An excellent article appeared this week in AMA News about physicians who have publicly acknowledged their medical errors.  They are using such disclosure as teaching opportunities for themselves and other health care professionals, and to highlight that systems improvement is the key to preventing errors.  The “I’m Sorry” legislation that has been discussed in various states reflects the need to provide transparency to patients and to make amends when they are harmed by medical procedures and decisions. 

The most interesting part of the article for me is a discussion of how to support physicians who have harmed patients through diagnostic or treatment errors.  I trained in the era of “shame and blame” when one person was assigned total responsibility for an error.  This led to a tendency to hide our errors from patients, hospitals and our colleagues.  Physicians judge themselves quite harshly and question their general competence or even their personal worth when faced with an error. 

In Boston at the Brigham and Women’s Hospital, a Center for Professionalism and Peer Support was created to reach out to physicians who are in the painful and lonely position of having acknowledged a medical error.  A number of physician peer advisors are available to reach out to their colleagues and ask about their wellbeing and offer support.  Similar programs have developed at medical centers around the country.  A compassionate and human approach to such colleagues can save careers as well as the lives of the physicians who are supported. 

Several years ago when I served on the board of MMIC (the professional liability company started by MMA some years back) we started the Physician Litigation Support Program.   Each physician facing a claim is personally contacted by a psychiatrist whose only purpose is to provide support and education to the insured.  We have received many thanks from recipients of this caring program.

If your training program or health care organization does not have a mechanism to support colleagues who have made errors or who face litigation, what can you do to get such a program started?  I suggest that the first step is speaking up and insisting that collegial support programs be proactive, supported and expected.  You should expect to hear from colleagues who want to work with you to make good work happen.  I suspect you will have richer friendships and happier patients as a result.   

A Common Ethical Dilemma

Patricia Lindholm, MD,
2010-2011 MMA President

Forgive my absence from the blog for the last few weeks.  I have good excuses.  (1) It’s summer in Minnesota.  (2) With all the rain I am mowing the lawn in my free time.  (3) My clinic went live with electronic health records this summer.  (4)  I adopted two dogs from the Humane Society and they need a bit of training.  I am sure I can find more if need be.

I have also been following some of the blogs and social networking sites as I troll for more information and resources on physician wellbeing.  On a bittersweet note, I recently read in the Huffington Post that Dr. Lee Lipsenthal (of whom I have written earlier in this blog) has a recurrence of his cancer and has been told that is the last season of his life.  His interview is a demonstration of a remarkable ability to be fully present in life as well as fully present to others as he anticipates their grief.  His work has enriched us and will continue to do so for many years to come. 

Dr. Lipsenthal was a presenter at the inaugural program of the Osler Institute’s conference on physician wellbeing last fall in Albuquerque.  I am happy to report that the conference will be offered again in the coming year, possibly twice.  You can follow the Osler Institute on Facebook. 

Of course I am also following Dr. Kevin Pho on his site KevinMD.com.  There are many posts of interest by physicians from around the country.  One that caught my eye this week was posted by Michael Kirsch, MD and titled, “Medical ethics in the office should not be a private matter.”  It appeared the day after I attended an ethics committee meeting in our newly integrated hospital and clinic.  We discussed bringing up examples of daily ethical dilemmas faced in outpatient medicine.  Dr. Kirsch lists several such outpatient dilemmas which resonate with me.  The problem is that no sooner is the issue behind me than I forget about it and lose the opportunity to fully discuss and analyze it with colleagues.  (I suspect it is a function of middle age.)

Here is an example of an ethical dilemma I have faced many times in my practice (I paraphrase):  A patient’s family member sends a note or calls to report some private information shortly before my patient’s appointment, with instructions “not to tell” the patient about who divulged the information, but hoping I can somehow dig into the matter.  Do you tell the patient about the conversation?  I have reacted differently on different occasions.  How about you?

How Minnesota Repealed Its Provider Tax

Patricia Lindholm, MD,
2010-2011 MMA President

An unexpected but satisfying item was tucked in the final Health and Human Services Budget Bill passed by the Legislature and signed by Gov. Mark Dayton this week.

Lawmakers have agreed to phase out the 2 percent provider tax and repeal it altogether in 2019.

I am relieved by this unexpectedly positive development not because it is a pocketbook issue – though it should help reduce health care costs – but because lawmakers are redressing a breach of trust with Minnesota’s medical community that has soured the relationship between physicians and state government, since this law was passed in 1992.

To doctors, it has always felt particularly unfair that the state decided to make those who must seek medical services – which is already a hardship – also pay a selective tax. Then when lawmakers rolled out the tax, they weren’t transparent about it. They explicitly prevented providers from telling patients about the tax by itemizing it on bills.

The courts ultimately overturned this provision, but the feeling of distrust toward lawmakers remained. Finally, after saying the funds would only go to MinnesotaCare, lawmakers broke that promise time and time again by using hundreds of millions of these dollars to balance the general budget. Once again doctors were left feeling distrust and disillusionment.

So I want to thank lawmakers for taking this step to repeal this law and repair the relationship. I must admit that after many years of the MMA working to repeal this regressive, selective tax, this victory seemed to come out of nowhere.

The person who deserves the most credit for this is probably House Majority Leader Matt Dean (R-Dellwood).  Rep. Dean saw early on that as the Affordable Care Act is fully implemented, there will no longer be a need for MinnesotaCare and the provider tax. The MMA worked with Rep. Dean early in the 2011 Session to help him draft a bill that would reduce the size of the provider tax as the need for it went down.  This bill passed a few House committees but did not move in the Senate. Then during the final budget negotiations Rep. Dean, with the support of Senate leadership and Gov. Dayton saw an opportunity to replace the provider tax with the new federal subsidies that will come online in 2014 for Minnesotans earning up to 400 percent of the federal poverty level.

I am convinced that the MMA helped lay the ground work for this breakthrough by working hard since the tax was adopted’s adoption to remind law makers that it is regressive, hits sick people harder than healthy, and adds to the overall cost of health care. Many legislators over the years, both Republicans and Democrats, agreed with us that this was a bad tax, yet there was never enough support to find the $450-$500 million it raises each year to replace it.
 
Now, our challenge over the next eight years will be to continuously remind legislators of their commitment to repeal the “sick tax” and ensure that this unfair tax eventually goes away.

A Generous Listener is a Healer

Patricia Lindholm, MD,
2010-2011 MMA President

Recently I had the opportunity to attend a seminar by Rachel Naomi Remen, M.D., in California.  It was called “The Healing Power of Story:  Toward a Closer Human Connection.”  Many of us are familiar with Dr. Remen through her books Kitchen Table Wisdom and Blessings From My Grandfather.  In her books she tells stories that indeed are healing to the teller and to the reader/listener. 

In attendance were physicians from various specialties, chaplains, social workers, nurses, psychologists and others in the healing professions.  There were people from the US, Canada, Australia, Britain and Germany.  There was no formal syllabus for this course. 

Each day of the three day course was divided into two parts.  Most of the time we were doing guided small group activities with groups of 2 to 7 people.  Each half-day session had a theme and we had the opportunity to delve within ourselves and tell our stories to each other.  We were taught the technique of “generous listening.”  We were to listen completely and mindfully to each person without interjecting any comments or questions.  I found myself having to consciously restrain my impulse to ask follow-up questions which I so often use in my practice.  Likewise as a story-teller I felt completely supported and heard by my story-listeners.  The results of generous listening were profound.

I was privileged to be a listener to a story by a physician who had been carrying a load of pain and shame since her residency days.  She had not felt safe in telling her story before.  She clearly was relieved to tell her story to a generous listener and felt healed by the experience.  I also felt healed by sharing a story with her about a loss in my life. 

It occurred to me that patients come to us so that they can tell their stories and be heard.  They are looking for the healing that we can provide simply by being generous listeners and confidants.  This is true of procedural as well as cognitive specialists.  Sometimes a patient has a distressing and perplexing story to tell and we squirm because we do not have “answers.”  What Rachel Remen taught us was that we are “enough.”  We do not need special knowledge or wisdom to be healers.  A story listener is a healer.  That is enough.  We are enough.

The Vanishing Oath

Patricia Lindholm, MD,
2010-2011 MMA President

Recently I came across a documentary-style independent film written and directed by Ryan Flesher, M.D.  The title is “The Vanishing Oath” and is a story about Dr. Flesher’s journey through burnout and his personal examination of the causes of distress that lead physicians to leave the clinical practice of medicine.  Those of us in clinical practice know exactly what bothers him and others.  He also interviews physicians around the country who have left medicine and allows them to tell their stories.  Random people on the street are also interviewed about their take on physicians and medical care in general.  I thought this film would be depressing but it was not.  It is about an hour in length and is accessible to the general public.  It would be an excellent holiday gift to your favorite insurance company CEO, malpractice attorney or legislator.  Check it out.  I believe I ordered it from Amazon.

The Vanishing Oath (excerpt) from Lisa Molomot on Vimeo.

Another very interesting book that I am almost done reading is titled Just Like Someone Without Mental Illness, Only More So, by Mark Vonnegut, M.D.  (Yes, he is the son of Kurt Vonnegut.)  Dr. Vonnegut experienced several psychotic breaks during his young adult years and was initially diagnosed with schizophrenia.  He actually has bipolar disorder and is a practicing pediatrician who trained at Harvard Medical School and Massachusetts General Hospital.  It is fascinating to see a first person account of serious mental illness from a successful practicing physician and teacher.  He also mentions many of the same frustrations noted in “The Vanishing Oath.”  Yes, he is one of us. 

It is comforting to see that the “elephants in the room” of medicine are exposed and acknowledged publicly by two articulate and courageous doctors.  Both of these works are enlightening to anyone with an interest in the sociology of medicine.  They might also be appropriate gifts to relatives who wonder why physicians need to attend to their wellbeing now more than ever.

Promoting well-being across professional disciplines

Patricia Lindholm, MD,
2010-2011 MMA President

I recently was invited to Rochester to speak about physician well-being to the clinicians at the Olmsted Medical Group. The group is unveiling a new program in professional wellness, led by a committee of four physicians. The first part of the program will be working on acute problems or distress, but further plans include preventive or proactive activities to enhance or maintain well-being in the medical workplace. I look forward to hearing about their progress over the next year and beyond. From the discussions that occurred after my presentation, it was evident that professional well-being is a timely topic indeed.

Many interesting ideas were generated by the Olmsted group. Allied professionals such as physician assistants and podiatry seem to have an interest in collaborating with us to promote wellbeing across professional disciplines. What a wonderful thought! Imagine what could happen if MMA combined forces with other health professionals in Minnesota to produce cutting-edge conferences and activities to revitalize our colleagues. Think of the valuable networking and relationships that would develop! If this dream excites you, too, I would love to hear from you, particularly if you want to help make them a reality.

Finally, let me share with you a short video recommended by our colleague, Dr. Craig Chambers. On You Tube called Validation. I think it will make your day.

Becoming an Iron Doc

Patricia Lindholm, MD,
2010-2011 MMA President

I would like to recommend a book called IRONDOC: Practical Stress Management Tools for Physicians, by Mamta Gautam, M.D., who is a psychiatrist and is known in Canada as “the Doctor’s Doctor.”  She works exclusively in the area of Physician Health and helps doctors care for themselves so they can care for their patients.

The title IRONDOC is an adaptation from Iron Man athletic competitions. For example, in the book Gautam offers 20 training tips (to deal with stress) which are like athletic drills. In addition, the book offers several chapters on the biopsychosocial factors that lead to unhealthy stress in physicians.  The reader is in the position of being “on the couch” of a skilled diagnostician.  Gautam adeptly outlines the common personality traits and defense mechanisms of physicians. 

Next she discusses the five early warning signs of stress and then the syndrome of burnout.  To overcome these obstacles, she develops the concept of the iron doc who is highly skilled in multiple areas, but not the best in every area.  So often we insist that we must be the best at all things, which is of course impossible.  If we are not the best, the thinking goes, then we are not good enough, or even worse, we are failures. 

Another aspect of this book I liked is that it is the size of one of those pocket manuals that we used to carry around in our white coat during training years (anyone remember the Harriet Lane handbook?).  The chapters are concise and the advice quite practical.  At the end of the book she recommends various resources the reader can consult for more depth in specific areas.

To see my other recommendations, visit the MMA’s new physician well-being page. We will be continually updating the site, so keep coming back!

Physician Wellness Resources

Patricia Lindholm, MD,
2010-2011 MMA President

I am always trolling for good physician wellness resources.  I have several to share with you this time.

You may have seen an excellent article in the New York Times on physicians taking control over their work hours and lifestyle. 

What is particularly compelling about this article is that it discusses the decision process of a third-generation physician in choosing her specialty.  It also discusses the reactions of her father and grandfather who had traditional endless-hour practices.  Many of us in practice can relate to all three generations and their points of view.

Another important and exciting resource recently came to my attention.  There is a conference in May in Albuquerque by the Osler Institute that looks wonderful.  I personally will not have time to attend but want to pass along the information to you.  This is the type of conference I have dreamed about creating for Minnesota physicians, but am glad that someone is doing it!  

Speaking of conferences I will be attending the Rachel Remen workshop on “The Healing Power of Story: Opening to a Deeper Human Connection.”  Many of you have attended Dr. Remen’s programs and I have heard nothing but rave reviews.  I am excited to go to this meeting in California in early June.  The longer I practice the more I realize that practicing medicine is largely about listening to and honoring our patients’ stories.  I also have come to appreciate that all human relationships are based in stories and these are the links that often connect us to each other.  I will be happy to share with you any “pearls” that I find at the workshop.

I have another book review for you in my next blog entry.  Be well!

Reflections on Resilience

Patricia Lindholm, MD,
2010-2011 MMA President

We have watched with awe and horror as events unfolded recently in Japan.  A massive earthquake, a devastating tsunami and then nuclear plants close to meltdown.   To a resident of Japan these events must have felt like the beginning of the end of the world.  Yet there were many acts of heroism including workers risking death by radiation poisoning to save their families and neighbors.  The Japanese are well known for their resilience.  I have no doubt that they will rebuild and work to make their country even more protected from natural disasters.

Resilience is the key to carrying on with life in spite of the pain, obstacles and other challenges that we face.  Every medical student must have resilience.  The brightest in college are now average students in medical school.  They must reframe their self-assessment and continue in a medical education.  As residents we continue to be trainees but assume more responsibility for the care and safety of our patients.  During residency a mistake can do very real harm.  The resilient resident confides in and relies on her fellow trainees as well as her faculty.   If we learn well, we discover that providing health care is indeed a team sport. 

I can recall a number of devastating experiences during residency having to do with poor outcomes for patients.  As we tend to be perfectionists, I am sure that you understand that I punished myself multiple times, feeling that I was not worthy of the profession, feeling that I had let someone down.  I felt like a fraud, an imposter.  I have had similar feelings as an attending physician.  In talking with close colleagues, I know that I am not alone in having these feelings. 

In moments of professional distress, we need each other.  We need to support and provide a reality check for a colleague who did their best and yet had a poor outcome.  The reality in the vast majority of cases is that our colleague is a good, caring physician.  We would do well to remind our colleagues of this again and again.  All of us have thought, “There but for the grace of God go I.”  The wounded healer feels alone and isolated and believes that he is constantly being judged by colleagues and other members of the health care team.  Sometimes the belief is well founded, which is an indictment of us all. 

In the 25 years in practice after residency, I have become more humble.  I have stepped off the pedestal I had built for myself over years of striving and pretending to be all-knowing, all-competent.  I remember once praying for humility some years ago, and then feeling afraid of what would logically happen if my prayer were fulfilled:  humiliation.  Well, that has happened but life did not end. 

Many things contribute to our resiliency, such as the love and support of our families, friends, and colleagues, and the appreciation of patients and their families.  Sometimes we also need professional help and therapy to get back on our feet.  I believe that reaching out for help is a sign of strength and wisdom.  Receiving care may feel unfamiliar to us but it is part of the complete human experience.  Try it sometime. 

Testing for Burnout

Patricia Lindholm, MD,
2010-2011 MMA President

In this blog, it has been my goal to provide useful resources to those of you who are interested in physician well-being. I hope to continue to do so in the remaining six months of my presidential term. I wish I could give you a feeling for the many connections that I have made with physicians across the country who are also interested in physician wellness. We have been sharing our work with each other in order to highlight studies and programs that exist or are being developed in the U.S. and elsewhere.

One such connection I’ve made is with Heather Fork, M.D., of Austin, Texas, who writes a blog called “Doctor’s Crossing” (DoctorsCrossing.com). She consults with physicians who face decisions about whether to make a career change or who are battling burnout. I warned her that I would shamelessly borrow some of her material for my blog.

One of the resources Dr. Fork discovered is a simple self test for burnout. It www.mindtools.com/stress/Brn/BurnoutSelfTest.htm. This nonvalidated tool assesses the three dimensions of burnout:

• Emotional exhaustion;
• Depersonalization – viewing others as objects, developing cynicism, separating ourselves from the people we serve; and
• Decreased personal accomplishment – less satisfaction in our work, joyless striving (what I think of as loss of a sense of purpose).

The prevalence of burnout is staggering, and it starts as early as medical school. Tait Shanafelt and Liselotte Dyrbe, two Mayo Clinic colleagues, have published an expanding volume of work documenting how burnout influences professionalism and the degree to which medical students, residents, and practicing physicians are affected by it.

If you think you might be experiencing burnout, take the self-test. If you get a high rating on the burnout scale, I encourage you to find a trusted advisor or therapist to help you refresh your spirit and your view on your work. It is possible to recover from burnout, as I can say that from my own-experience. Do yourself a favor and keep your flame alive!

Finding Balance

Patricia Lindholm, MD,
2010-2011 MMA President

Recently I became aware of the work of Lee Lipsenthal, M.D., an internist who developed a program called “Finding Balance in a Medical Life.”  He has written a book by the same name that I suspect will be on my reference shelf and used for many years into the future.

The first half of the book summarizes what is known about the physician personality, the state of physician health and the prevalence of burnout.  My readings in the area of physician wellbeing over the last two years confirm his analysis.

The second half of the book contains a panoply of tools which can help us find our way out of burnout and back to a life of balance.  Many of these are familiar to those of us who have studied psychology and neuroscience in the last couple of decades, such as cognitive therapy and emotional shifting.  Mindfulness meditation is discussed in some detail with exercises that can easily be done over 5-10 minute periods.  There is an interesting chapter on “Psychosynthesis” which discusses how to identify our personality and sub-personalities and how to use them to respond to a variety of situations.

By serendipity, I also came across the keynote lecture that Lipsenthal delivered to the annual Scientific Assembly of the American Academy of Family Physicians in 2010 in Denver.  The AAFP shared a video of his presentation on their web site for those of us who were unable to attend the meeting.  During that talk, Lipsenthal revealed that he was undergoing treatment for metastatic adenocarcinoma of the gastroesophageal junction.  Thus far he has survived about 18 months from diagnosis and looks pretty good but is well aware of the poor five-year prognosis.  By already having established a habit of meditation and daily expressions of gratitude, he was prepared to face the illness with calm. 

The book and the talk both ended with the following words of wisdom:  Balance is knowing that today is a good day to die; that you have lived fully, lovingly and without remorse. 

May we have many good days.

MMA Moves Forward with Physician Well Being Effort

Patricia Lindholm, MD,
2010-2011 MMA President

I wish to share with you the progress to date with the physician well-being initiatives at MMA.  At the January Board of Trustees meeting, the board approved the proposal of the Physician Well-Being Task Force.  Soon we will be discussing how to implement the recommendations of the group. 

A member survey conducted by the task force indicated strong interest in having regular articles in Minnesota Medicine on topics related to physician well-being.  I hope that by now you have read the January issue that was dedicated to the topic.  I am so proud of the contributors to the journal, many of whom were on the task force.  If you have not seen it, take a look or go to the Minnesota Medicine web site.  I truly believe this issue will be a valuable reference for us in years to come.  For those of you who are interested in member recruitment, this journal would be a good promotional piece for MMA.

It is my hope that we will offer or sponsor retreats for those of us who need to have “time out” to reflect, rejuvenate and learn new techniques to reduce stress in our lives.  It is also my hope that these and other offerings will promote the formation of “community” among us.  It occurs to me that one of the things most lacking in physicians’ lives is a sense of community with our colleagues.  I am thankful to my local colleagues who have come together for community in our small support groups.  There is a great deal of healing and soul-feeding that occurs when we can be truthful, trusting and vulnerable to each other in community.  If you would like to see a similar group in your medical community I would be happy to share our experience with you. 

I continue to be impressed with the Canadian Medical Association’s efforts in the area of physician health.  I would like you to know that the second Canadian Conference on Physician Health will be held in Toronto October 28 and 29.  I am planning to attend!  You can get information about the conference at www.cma.ca/physicianhealth. 

I am currently reviewing a good resource on physician wellness and plan to share it with you soon as a “book review”.  Stay tuned.

Be well!

Moments of Grace

Patricia Lindholm, MD,
2010-2011 MMA President

In January, I was a guest at the Zumbro Valley Medical Society’s annual meeting.  Because I live five hours away from Rochester I checked into a local hotel to spend the night after the meeting.  Subsequently I had two consecutive days off for travel. 

The meeting was an elegant affair with award presentations, a fine meal and an excellent talk given by Sanne Magnan, M.D., the former Minnesota Commissioner of Health.  My hosts were extremely gracious.  The awardees were all inspiring individuals which caused me to ask myself, “So what have I done with my life?” 

Don’t get me wrong.  I know as a physician my work helps people every day and is meaningful.  I am also in a leadership position in my state medical association.  These are facts.  However, internally there is often discord between fact and conviction. My own faulty wiring at work, I suppose.

During a period of socializing at the meeting I was approached by Harriett Hodgson, former president of the MMA Alliance.  She is an accomplished journalist and author.  She came to present me with her most recent book, “The Spiritual Woman.”  What a gift!  She has a beautiful introduction about the many varieties of meditation and their value and usefulness.  The book also includes a collection of inspiring quotations that can be used as the basis for a daily meditation.  I knew that this gift was a moment of grace.  Perhaps my encouragement of an open discussion of physician wellbeing has significance after all.  Indeed this gift was nourishment for the soul.

The experience also reminded me that in medical practice we are presented with moments of grace more often than we recognize: the gratitude of a patient who takes the time to write a card; the sincere “thank you” from a person who felt heard and cared for; the affection that develops when we care for patients over many years, and the hugs from children or from the elderly.  These are priceless. 

On days when we are discouraged and wonder whether we ought to have chosen a less stressful career, we are likely to have had a moment of grace somewhere, if we only had eyes to see it and the sense to appreciate it.

Medica Gets Zero Stars for Physician Relations

You may have seen or heard the voices of myself, Past President Ben Whitten and others representing MMA in the press this week.  We have been working hard to put forward the concerns of our members about Medica’s flawed individual physician rating program. 

Despite our efforts to work with Medica behind the scenes and in public, Medica decided to ignore the input of physicians and move forward with their program.  MMA met with Medica in December and shared its concerns.  We sent a letter and requested a delay in publication of the program a week before its public release and never heard back from them.  That is disrespectful of Minnesota’s physicians.

The MMA is concerned about known errors in the data, the inadequate time for review and validation and clearly insufficient statistical testing.  Medica’s program could harm physician reputations, undermine the physician-patient relationship, and mislead Medica patients and purchasers of health care.  MMA’s request that Medica address our specific concerns was completely reasonable and justified.

I am saddened that Medica chose to ignore our concerns and to dismiss our overtures to work together.  Minnesota has had an admirable culture of collaboration between health care organizations in the past.  To ignore the input of physicians is not the way things are done in Minnesota.   

The MMA was a founding member of Minnesota Community Measurement and has supported state and federal policies to expand performance measurement.  We have invested significant resources and physician expertise to inform and improve the state’s peer grouping program, which will generate cost and quality measures of physician clinics and hospitals.

Medica has truly missed a chance to work with physicians to design a useful tool and strengthen its relationship with the physician community.

Professionalism, Nature or Nurture?

Patricia Lindholm, MD,
2010-2011 MMA President

I have been thinking about the concepts of collegiality and professionalism for a number of months. Trips to the dictionary have been unsatisfactory. After consulting a number of them, I found very limited definitions such as “belonging to a college, such as the college of cardinals in Rome” or being a member of a specific professional group.  In other words, there was no behavioral aspect to the definition of collegiality.  Perhaps like pornography, we “know it when we see it.”

Recently I read an excellent article in JAMA, “A Behavioral and Systems View of Professionalism,” by Cara Lesser et al that shed light on this issue.

The premise of the article is that professionalism is a set of competencies that can be taught and learned and that it must be practiced to be developed.  Also we are capable of improving upon professionalism as we continue in practice.

What is professionalism? According to Lesser, professionalism is not an inherent character trait or attitude.  Professionalism is defined as a set of behaviors.  It appears that collegiality - working collaboratively with other physicians and demonstrating respect for them all in the service of the patient – is one of those behaviors.

The article also demonstrated how external factors in the practice environment can affect professional behavior. Financial incentives such as pay for performance are not motivators to professional behavior.  Pride of purpose and intrinsic motivation are more important.  There are therefore two essential players in the service of professionalism: the individual interactions between doctor and patient and organizational management and governance. 

The good news of this research is that there are no hopeless cases.  All of us can learn the skills of professionalism and all of us can grow and refine our professional competencies throughout our careers.  This is one source of resiliency.  And resiliency is the preventive medicine and antidote for burnout. 
When our behaviors reflect our values we are whole people and much happier people.  We owe it to ourselves and to our patients to work to make the small and large health organizations more conducive to professional behavior and to eliminate perverse incentives in the system.