Flying Tigers, and Boxing Joe Louis … in the exam room?

I was a nervous first year intern on the internal medicine hospital service. Our team had come down to the Emergency Department to accept the patients being admitted to our service. My resident turned to me: “Room 3 is your next patient. Pneumothorax. We need to care for this patient for a few days and stabilize his lungs until we can remove the chest tube vacuum. Obtain a quick history and exam and place his admission orders.”

I went in to chat briefly with the patient. Since we were busy meeting a host of new patients, I just had the briefest of conversations with him; he had gotten very out of breath, driven himself to the ER, was found to have a collapsed lung (pneumothorax), and had a chest tube vaccuum inserted to re-inflate the lung. Got it. I wondered how it happened, but that mystery would have to wait.

from aliem.com

Later that evening, I went back in the room to chat with my patient with pneumothorax. The chest tube was working, he was feeling less short of breath and more comfortable speaking. He had a long history of injecting cocaine, and as a result of frequent use of needles, had scarred all the accessible veins in his arms and legs. During one of his previous hospital stays, he noticed nurses putting IV’s in other patients’ necks, and found out that he, also, could use a neck vein to inject. This worked well for a time, but THIS time he had inserted the needle too far and punctured his lung. He felt the “pop” and then began feeling short of breath, and immediately drove himself to the hospital, where he passed out in the parking lot at the ER entrance. Fortunately, someone saw him, and the ER team brought him in and resuscitated him.

from lecturio.com

I thought: “this is a cool case. Self-injection into a neck vein leading to pneumothorax.”

My resident agreed. “Why don’t you present this at Dawn Patrol tomorrow morning?”

There it was. It was finally my turn to present to the dreaded Chair of Medicine at Dawn Patrol, the infamous rounds where the post call team would assemble at 6:30am and one unlucky intern would present a selected case history and have a thoughtful ad-hoc pathophysiology discussion.

At 6:30 am precisely, the looming presence of Dr. Silva arrived in the white-scrubbed hallway. “G’ mornin’ everybody! How’re we doin’? Who has a case?”

Joseph Silva MD, Dean (formerly of UCDavis School of Medicine) via California Northstate University website. Hi, Uncle Joe!

“Good morning Dr. Silva, I do.”

“Oh good! Okay CJ, go ahead.”

I was so flustered I didn’t even correct his mis-remembering of my name “CT”, and I just plunged ahead. “This is a 31 year-old prisoner, who presents with sudden onset shortness of breath and is admitted with pneumothorax. His history began earlier yesterday when …

“Stop.”

=I paused=

“Pneumothorax. Interesting. What is his educational background?”

from gentledoveministriesinternational.blogspot.com

“… Um, he is a prisoner. I did not ask.”

“So, he could be a medical student, and you would not know?”

“No sir.”

“Hmm. So you might be speaking disrespectfully to a medical professional and you didn’t find this out. Okay. Is he a rose gardener? You know, sporotrichosis thrives in rose bushes and can cause spontaneous pneumothorax.”

“Um. I don’t know.” (Head hanging lower)

“Or, maybe has he recently purchased or cleaned out a pickup truck he bought from the Forest Service? You know that coccidiomycosis is endemic in the Central Valley nearby, so called “Valley Fever” that can commonly cause spontaneous pneumothorax.”

“I don’t know sir.” (Staring at the ground, hoping it would swallow me up)

from slideshare.net

“You know what? We need to change this. I have been disappointed this year with Dawn Patrol presentations where we have gathered inadequate Social History. This is going to change today. Starting now, Dawn Patrol presentations shall BEGIN with a FOCUS on SOCIAL HISTORY.”

“Yes, sir.” I mumbled my way through the rest of my desultory presentation, the amazing external-jugular self-inflicted needle-puncture of the apex of the lung forgotten in the shame of inadequate “social history” skills I demonstrated that day.

After rounds, my fellow interns came up, punched me (hard) in the shoulder “Thanks ‘CJ’. Good job. As if we weren’t working hard enough already, now we have Social History to worry about too.”

For the rest of that year, every University of California Davis intern gathered a world-class, comprehensive social history. We knew every patient’s educational background, what schools they went to, what they studied and enjoyed, what occupations they held (every one of them since the beginning of time), what hobbies they had, what their families were like, how active they were, what groups they belonged to, every place they had ever lived or visited. 

As for me, for a long time the Social History was my albatross. I wanted to avoid ever getting caught with my pants down again. For the remainder of my residency, my fellow residents never let “CJ” forget what he brought down on all of us.

Over the years, my focus on Social History influenced my interview style. My history-taking skills improved. I did not even notice that I was getting to know my patients better. I saw my patients more as humans and less as diseases.

Joe Louis | Boxing history, American boxer, Joe louis
Joe Louis, heavyweight champion, from pinterest.com

I learned that one of my patients used to practice-box with Joe Louis, the heavyweight champ.

from http://chinaburmaindiawwii.blogspot.com/2015/06/flying-tigers.html

One of my patients flew with the Flying Tigers who challenged Japanese invaders over communist China at the beginning of WWII.

It turns out, the entire history of the world walked in and out of our exam rooms and hospital beds, if we were just aware enough to ask. 

Dr. Silva was brilliant. The surface lesson was: take a good history. Get to know your patients. They’re trying to tell you the answer to the questions you have about their illness.

The second lesson that I only came to understand years later: getting to know your patients, whether through social history, or just being generally curious about another human being, was the gateway to enduring, therapeutic relationships, for everyone involved.

Thanks, Uncle Joe.

Skid marks … and Bad Parenting?

Author and son, out for a ride.

My son and I were out for a bike ride. It was a beautiful Saturday afternoon, and we were learning to pace line and having a good time. Having recently watched the Tour de France, we had enjoyed how the US Postal team cyclists were less than a foot apart on the road, benefitting from the wind shadow of riders ahead. I told my son: 

“Son, did you know that trailing cyclists in a pace line can save up to 1% of energy for every mile per hour they’re traveling? In the Tour, cyclist pace lining at 30 mph could save nearly a third of their energy doing that.”

My son, either breathless on the bike, or couldn’t care less: “Huh.”

We were zipping down the bike path along the Highline Canal in Denver, the wind in our hair, having a pretty good father-son afternoon. We were traveling about 15 mph on long clear stretches of smoothly paved, tree-shaded asphalt. We were alternating the lead. For now, I was leading, and he had developed enough consistency and confidence to be within a foot of my back tire. 

“Do feel the difference? Are you in the wind shadow?”

“Yeah! Actually, this is pretty cool!”

What could be better, an outing with my son, a beautiful day, imparting an occasional word of wisdom, spending time together. I was being a good parent. 

Ahead was the dip in the path towards the tunnel underpass at Iliff Avenue, where the path narrows and pedestrians share the right-of-way. As we approached, I suddenly spotted a pair of elderly walkers heading down into the tunnel, and we were already nearly upon them. Worse, there were bikes emerging from the tunnel from the other direction. I had no place to dodge. I signaled to slow, and immediately hit my brakes. My 16 year old son, immediately behind and slightly to my right, slammed on his brakes as well, squealing to a stop. I stopped just short of the pair. My son, squeezing the brakes for all he was worth, with no escape direction, struck one of the women, who shouted “Oh!”, and went down. 

We were horrified. 

We leapt off our bikes and apologized profusely. 

Fortunately, the woman was able to stand after a bit, limping. 

After glaring at us, she and her partner let us know exactly what they thought of our speeding down the path at unreasonable speeds and striking pedestrians. 

We walked them to a nearby bench and sat with them for awhile, before we rode on, much more sedately, having lost the joy of the day. After a brief period, we decided to abandon the rest of our ride, turn around and head home. 

We passed them again on the path home, and heard them say as we passed “those were the guys.” We felt terrible. 

It took my son 2 months to get back on a bike again, and we have never pace lined since that day. We both take it slower now, particularly around ANY pedestrians or any blind corners or tunnels. The speed and the workout can always wait, right? Why did it ever need to be another way? I see others on bikes flying by, narrowly missing pedestrians, and wonder how we ever survived as a community, as a species. 

Fortunately, my son and I still go cycling together. Thank goodness. 

The scene of the crime.

We approach the spot. Incredibly, it has been 5 years, and the skid marks are still there, indelibly marked into the concrete despite many seasons of sun and rain. He looks at it and sees his shameful past.

“There it is Dad, that spot where I almost killed someone.”

I’m surprised. I had hoped he had let that go, but he had not. I told him that I understood why he felt bad, but I also helped him see that you ought to be able to trust your parent’s judgement, but that =I= had let him down, and worse, I had literally pulled him into a situation where he could not avoid hurting someone. I told him: 

“Those skid marks are not symbol of an error on your part. They’re a symbol of my Bad Parenting.” It was my shame, and not his. 

In the years since, this moment has lost none of its painfulness. Somehow, excruciating emotions are the yellow highlighters of our lives. This memory is as indelible as those skid marks that I see every time I ride by.

Be careful out there, y’all. 

The Boys in the Boat (book review)

From the Everett Herald

The Boys in the Boat: Nine Americans and Their Epic Quest for Gold at the 1936 Berlin Olympics https://www.amazon.com/dp/0143125478/ref=cm_sw_r_cp_api_glt_fabc_M81Q4K17N2RTE3JE8RYA

OMG. 6 out of 5 stars. This was intended as a fun summer read. But also, it has catapulted me into the Great Depression, WW2, Leni Riefenstahl and groundbreaking cinematography, the rise of Nazi Germany, collegiate regattas, and the elusive and ephemeral ‘swing’ of rowing. I listened to the audio book. I usually listen at 1.25x or 1.5 or sometimes even 2x: the narrative is usually more important than the writing.

But this. The story, even though the end is known, is riveting. The story of Joe Rantz is the heart and soul of the tale. The author weaves so many threads into a tapestry that envelops and then propels you forward, like the coiled might of 8 undergraduate underdogs, their brilliant coxswain and a cedar-hulled shell, coming from behind as 70,000 voices yell ‘Deutschland! Deutschland!’ to the German boat several lengths in the lead.

This, I listened to at 1.0 and savored every moment.

Go ahead, read the other reviews, but don’t tarry: the Boys in the Boat await you. I am jealous that you will experience this for the first time.

Here’s an 11 minute retrospective, including the granddaughter of Joe Rantz.

What TikTok teaches us about effective communication

Those of us stuck in the “last century” take heed: TikTok and 15 to 60 second videos are IN.

My Tiktok channel: https://www.tiktok.com/@ctlin99

The TL;DR? 15 seconds should be the length of your educational videos. Wanna know why? and how? read on.

I was a Late adopter of Facebook

I’ve been thinking about the evolution of social media. In early days, I was a late adopter of Facebook, not getting why it was any better than email. Now, I get it: saying something once allows your network to see it, from close friends, to casual acquaintances. Medical residents explained to me that photos and memories were easier to share more broadly. AND, an existing large network made participation more valuable (hey! look at all the people I already know on here!).

Just like in the old days, getting a telephone was INCREASINGLY useful if there were MORE people and stores you could call. The network effect.

LinkedIn, Twitter

That led me over the years to LinkedIn (mostly for work contacts and posting my CV and work products publicly) and Twitter (still figuring it out, but a good way to keep up with news if you curate your network carefully, and also a way to post blog content). Also, Twitter allows you to curate for yourself an international community with similar interests, like #medtwitter.

And, my brilliant younger sister taught me that Twitter could also be good for lecture commentary and discussion (she will give a talk on 2 screens: one with her slides and another with a live pre-filtered Twitter feed: how brave! and give out a custom hashtag, like #postitpearls_lecture, and ask the audience to submit questions this way: wow).

YouTube

And, some of you know that I’ve dabbled in amateur song-parodies with EHR songs on my youtube channel.

IFTTT, blogging

Finally, I’ve figured out how to blog regularly and then use IFTTT to cross-post my content auto-magically to my other platforms (Facebook page, Twitter, LinkedIn) so that I can seem more connected and omni-present than I really am (Thanks for another great tip, Sis).

Tiktok?

BUT! TikTok is another thing altogether. My colleague and her daughter suggested that I take my latest Hamilton parody song (that I had gamely posted to YouTube and here I am shamelessly showing it to you again)

#notthrowinawaymyshot and now post it on TikTok, a post-millenial social media platform restricted to 60 second videos. Leaving aside the recent kerfuffle about Chinese ownership and control, this is qualitatively a different animal: getting your thoughts across in 15 seconds (preferred duration, and the time restriction being a result of the music industry’s maximum replay length of a copyrighted song). It has since been extended to 60 second maximum if you have an original soundtrack on your video.

So, I dove in. Unlike my “dozens” of views on my YouTube channel (with which I was satisfied; my broadcast domain is, admittedly to a relatively small physician informatics audience), my TikToks quickly blossomed to nearly 1000 views in 2 days.

Wow! I thought. I am AMAZING on TikTok.

What I did not appreciate is the 15 to 60 second format is much more attuned to the rapid “swipe” of post-millenials, and EVERYONE racks up lots of views. And, ultra-short videos are so easy to consume one after the other. AND, TikTok doesn’t need you to establish your network before your video gets out there; it shows your video to a random selection of viewers, and then those who LIKE it or SUBSCRIBE to you trigger the algorithm to show it to more viewers. So, an easy way to game the system is to use trending (but highly inaccurate) hashtags, like #superbowl, etc. Sadly, this user does not seem to have understood, or be willing to follow, some of these informal rules.

Furthermore, if you read online chatter about TikTok views “500 views total, is pretty sad; what you want is 500 views per hour.” For example, Nathan Evans, of Sea Shanty fame? He went viral at about 250,000 views, and now he’s at 12.9 million. Oh, well. Here’s my paltry Covid Sea Shanty, currently at 62 views (not 62,000) and SIX LIKES.

In contrast, our Informatics team at UCHealth just retired/deleted a 17-minute video I made a 10 years ago for a full “walkthrough” of how to use the Electronic Health Record for our ambulatory clinic physicians. Whew, how out of touch was THIS guy? Here’s a one minute snippet of the kind of video I posted back then, when we were on Allscripts Touchworks. So young, so naive.

Our more recent training videos are more like 1-2 minutes and focused on ONE technique or tool. Now, I’m thinking, maybe we need to shoot for 15-30 seconds. The cool thing about TikToks is that you can trim seconds, speed things up, because those viewers who “get it” can be done watching in 15 seconds, but the video can be paused and also it automatically replays so the viewer can catch subtle details. Hmm, is this a paradigm shift? Should we embed TikTok length education videos into our EHR?

Put Road Signs On the Roadway

As we say internally, shouldn’t we put the Road Signs and Driving Directions (our tips and tricks) on the Roadway (where our users are actually using the EHR) and not in the Garage (our online reference library and training webinars)? Aren’t our users more likely to click on tips WHEN they’re doing work, rather than when “oh, I have some time, let me see what I can go learn.” (which is never)

Austin Chang is my hero

There clearly is an entire evolution of thinking needed to succeed in this TikTok medium. And I don’t have the savvy (yet), the luck, or the persistence to grind out the many tries needed to break through. However, there are medical professionals who have. For example, Austin Chang.

Austin is … well, just go watch him. In 15 seconds, with hilarious music over-dubs, he uses captions and terrible dancing while in scrubs (ok not so terrible), to get his medical facts out there.

I both bemoan the general public’s deterioration of attention span (15 seconds now? Really?) and his ability to fit his tiny education bites (bytes?) into this format. It works. Some of his TikToks are over 2 million views. On MEDICAL TOPICS. Nice. Here’s the NYTimes writing about him.

This reminds me of reading The Shallows, a book about what the Internet is doing to our brains. Are we losing the ability to read a book? I don’t know. I, for one, did not finish reading the book. Ironic.

CMIO’s take: Beat ’em or Join ’em? What are YOU doing about TikTok in your field?

All successful projects have a great story. What is yours?

Anyone out there trying to get a project funded?

Maybe, some of you are trying to get the attention of leaders in your organization to try an idea that is important to you?

Perhaps you’re frustrated that colleagues don’t agree with your viewpoint, and no one seems to listen?

Or, some say “your explanations are just so dry, we miss your entire point.”

Yes?

Consider: that in healthcare, and as scientists, we are taught to memorize our facts, build on scientific principle, and be rigorous. We rarely take the time to learn storytelling and communication. In fact the phrase “tell a story” in medical interview implies that you are lying.

Well, time to change all that. As informaticists, as medical professionals, as scientists, we need to be masters of storytelling. It is the ONLY thing that changes minds.

‘Sure, keep doing the great science that we all do, but let’s learn to communicate.

One of my favorite instructors in communication is Andy Goodman. At his website, you can sign up for his newsletter (and read archival issues, here is a good example about SMALL stories, and another one about Powerpoint use). His center is dedicated to improving the communication of all-important non-profit companies.

Here’s an example of his paradigm shifting ideas: “Why are non-profits named after things they are NOT? Why not name them for things they are FOR? Non-profits should be called “Public Interest companies.” Huh. How about that?

And, watch his talk above.

CMIO’s take? We all need to talk gooder.

Wall Street Casual (NYtimes) vs Loki?

Some of you remember me, with pre-pandemic bow-tie.

Soooooo long ago. Good old days?

During the pandemic, our family went into full-on Joseph Lister anti-sepsis mode. I’d dress for clinic in a button down shirt, casual pants, mask and face shield, strip down in the garage on getting home, yell “contagion!” to clear my path to the laundry, and wash everything in hot water immediately. No dry cleaning piles, no laundry baskets. Right into the machine.

No watch, no bowtie, no glasses, no dress shoes. My shoes were washable Keens. My wallet became a paper-clip with $20, a credit card, my entry card and ID, and a folded letter that certified that I was essential personnel in case I got stopped at a quarantine checkpoint.

Here we are a year later, and clothing-wise, not much has changed. Casual seems dressy enough. We’re still masking, and starting Monday, I think we’ll be back to wearing face shields, as the Delta variant rages on.

I think the Loki variant is a lot more fun, personally.

Dark Rounds – Faith Fitzgerald MD

Dr. Faith Fitzgerald, Master of the American College of Physicians, and one of my mentors

https://www-acpjournals-org.proxy.hsl.ucdenver.edu/doi/pdf/10.7326%2F0003-4819-138-9-200305060-00015

I came across this article again, written by one of my mentors, Dr. Faith Fitzgerald in 2003. I was always astonished that her discussions, and her talks, even at Morning Report, that off-the-cuff discussion of cases the morning after a busy overnight on-call, seemed to come out of her mouth, like fully formed medical textbook chapters.

As interns and residents, we were riveted, and also despaired that we would ever achieve that level of knowledge and mastery of medicine.

In fact, this worked directly against me, when, in my naiveté, I suggested that she use Pubmed, or the online search tool (in 1989!) to find relevant medical articles. As she would regularly devour volumes of medical literature, she could easily cite more relevant articles, and faster, than I could type in MeSH search terms. And, she never agreed that the introduction of electronic health records was a positive influence on healthcare in this country.

Nevertheless, I always looked up to her thoughtfulness, to her skill as a master clinician, and her writings. If you’re inclined, use “scholar.google.com” (to find research articles) and search for “Faith Fitzgerald” and “annals” and you’ll get numerous personal viewpoint articles she wrote for the Annals of Internal Medicine. They’re one page and beautifully written anecdotes.

“Dark Rounds” was a particular favorite (link above), about how a frustrated attending physician, in the too-busy environment of hospitals, teaching rounds, rush-to-discharge to shorten “length of stay” found a way to connect with her patients.

CMIO’s take? Master physicians like Dr. Fitzgerald are rare and precious. How do we grow more like her?