A memory keeps popping up which is pretty shameful but does not have a disaster ending. When I was a 16 or so my best friend and I decided to take an overnight drive to his dad’s house near Yosemite from Los Angeles. The trip was about 5 hours. This is well before my ER […]
This post is for my emergency medicine colleagues and our Essentials of Emergency Medicine community. You are the reason we do what we do at Hippo. Our mission is to empower you, the people of medicine, to learn, grow, and thrive. To that end, we have some updates about COVID-19 and the Essentials of Emergency Medicine 2020 conference in San Francisco in May.
We have been hard at work trying to figure out the best way to accomplish our mission for you educationally, as a community of emergency clinicians, and as customers during this pandemic. If you’ve not yet seen our COVID resource hub, please check it out and share it.
We are incredibly grateful for your efforts at this time.
Essentials of Emergency Medicine 2020 update
We tried hard to innovate our way into keeping EEM 2020 alive this year. But, alas, it is time to focus on what we can do for the people of healthcare today. EEM 2020 is cancelled. We’ll see you next year May 25-27, 2021 in Las Vegas!
Thank you for being a part of the Hippo and EEM community, and for what you’re doing right now in this pandemic. Please reach out to me or the Hippo team for anything.
Wine and chocolate are great and horrible
I’ve had a personal morbid fascination with the medical literature since medical school. I’ve lived long enough to see several things be portrayed in the professional and layperson literature as miraculously beneficial treatments only to be the polar opposite in the next study or after failing to be replicable long term. It’s nuts. I’m not a statistician but I’ve been trying to become more facile with statistics (I highly recommend this amazing little book) and especially the many kinds of bias that can influence the “conclusions” of studies.
It happens in all areas of medicine, although it is more likely to be in the New York Times when the topic is chocolate or wine or how working out for 32 seconds is the same as running 10 miles. But, if you live long enough you’ll see us go change our opinions on things we espoused as gospel over and over again. Why? So many things can steer us away from the truth that it almost makes it more likely that we are wrong. I will write more about this because it is too dense a topic to cover in one post but there is one really cool article from back in 2005 that I always cite in these kinds of discussions.
Great JAMA article
Published in 2005, this article by John Ioannidis in JAMA is so interesting. He studied all of the research from major journals that had been cited >1000 times in the literature from 1990 to 2003. These are high impact studies and practice changing findings. He then asked how often these studies’ conclusions were contradicted by later studies, had been shown to have much less effect than later studies,
The good physician knows his patient through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is his interest in humanity, for the secret of the care of the patient is in caring for the patient.” -Dr. Francis Weld Peabody, 1927
The Hippo Education crew took a well-deserved retreat to New Orleans this past week. As a remote company we treasure the opportunity to come together IRL. The company was wonderful, the city fascinating, and the beignets plentiful.
One of the highlights was this medical museum. The gentleman that gave us the tour was phenomenally knowledgeable. The whole experience motivated me to start looking for a good book on medical history. While I was doing that research I came across, once again, the quote above by Dr. Peabody. I think it’s worth a deep look. (I do wish it had more inclusive pronouns but, you know, 1927).
Lots of things about this quote stick with me.
That a physician’s knowledge is bought dearly. So true. That time, sympathy, and understanding should be “lavishly” dispensed. So true, and so hard now. That the reward is the bond with the patient. Holy curse word, so true and so challenging to forge that bond in a modern rushed setting.
The last sentence is beautiful.
One of the essential qualities of the clinician is his interest in humanity, for the secret of the care of the patient is in caring for the patient.
An interest in humanity. I think that is as deep as it gets. As medical practitioners we tend to have a deep interest in humanity. I often have a tough time describing that but it is just that. I am fascinated by what makes humans tick psychologically, spiritually, and physically.
What we’re trying to do at my company is to focus on the humanity of the people doing this clinical work. What do they (we) need? Education to start. A deep foundational education helps us focus on the rest of the stuff in this quote.
But, I highlight this quote here to bring our attention, for a moment, back to the real reason we do this work. And, to see if we can look at our extremely busy patient care day through a different lens, if only briefly. The road was long and hard to get here. The deeper rewards are, and should be great. We are here for the humanity of it, in all of its messy reality.
Maybe if we meditate on that quote for a moment, we’ll gain some perspective. I think it speaks volumes. It makes me proud.
I have had a task on my to-do list for forever, inspired by all kinds of deep people, to write thank you notes to people who had a profound impact on my life. I don’t know why I never get to it. But, the other day I did one. I happened upon the email address of a doctor named Rinaldo Canalis. I’d been looking for a place to send him a note that wouldn’t get thrown away (like a hospital address might) for years.
About 30 years ago, Dr. Canalis and team helped rid me of a benign but invasive tumor near my pituitary. In caveman times (or probably in any decade before it happened, truthfully) it would’ve been a death sentence. But, because of modern medicine, the people who dedicate their lives to it, and a good helping of luck, I emerged out the other side, cured. The journey took a few years and, itself, had a tremendous impact on me but I’ll save that for some other time.
Here is an edited letter I sent to Dr. Canalis below (he responded today so if you’re interested I’ll post that later). Sharing it here, I think I just want to get across how incredibly important the work that we do as clinicians is and the outsized impact it has on individual patients. This is our reason to exist at Hippo. If you’re a clinician and you think the radio-silence from most of your patients implies that they don’t appreciate what you do, I think you’re wrong. It took me 30 years to write this. I’ve had a few of these written to me over the years, but only a very few. Here’s to hoping we all get a few more, but to remembering that, for a myriad of reasons, there are countless people who deeply appreciate you. They just haven’t gotten around to telling you yet.
Hi Dr. Canalis, I happened upon your email address today for the first time, after thinking about writing to you dozens of times over the years. I hope this reaches you! My name is Aaron Bright and I was your patient as a college student when […]. Needless to say, the episode had a profound impact. But, you in particular, and every single time I visited your busy clinic, had an outsized affect on me. You are the person I emulated when I tried to figure out, years later, how I wanted to be a doctor and how I wanted to make patients feel. I’m sure you’ve heard it many times but I have never met anyone with a more sincere, authentic, caring, professional, and calm-inducing bedside manner. I remember my dad calling you, concerned that he had changed jobs and that his new insurance may not be acceptable to the hospital. You told him “Mr. Bright, we are committed to caring for your son, and we will do that, no matter what, regardless of his insurance, we will see him through this.” My dad got off the phone and cried for 5 minutes. He had been so afraid to lose you. You had no small part in my choosing to go to medical school. I chose emergency medicine, and have conjured your memory in countless patient interactions. I do my best impression of you when I can feel the fear in the room, see the terror on a parent’s face, or sense that this person needs to really know that I know what I’m doing. Subtle stuff, best understood by example. Back when I was your patient, I was young, scared, and overwhelmed. I tried hard to make that tumor teach me something, and it did teach me a ton. I see it as one of the most important times in my life. I would not trade it away (although I would not wish for it again). Your technical skill helped save my life […]. But your humanity changed my life and has been a main ingredient in my personal style of interacting with patients. It has also helped form the mission of my efforts in education. I remember how you walk in to the room, fold your arms, look into the eyes of me and my terrified parents, give a few seconds of silence and space to show you are present, and then launch into the problem solving. I remember looking forward to coming to see you for reassurance and leadership along the path. I remember you going out of your way to track down a bulb syringe to replace the mutilated one I’d been using to clear out the giant crusty […redacted for gross factor…] every day, I remember you laughing at my dark humor. You were truly essential to my recovery in every way. Words will fail to show the impact you had on me and my family. But, I will just say, in the most sincere way possible, thank you. Respectfully,Aaron
I use this meditation app called Waking Up by Sam Harris (we are in no way affiliated). Today someone asked me, what is the most important app on my phone (an existential question?). Waking Up might be it. There are lots of other good meditation apps.
Waking Up is decidedly untied to any religious tradition. It has a course that covers meditation basics. And, it feels authentic and genuine. In other words, it doesn’t feel like I need to enjoy wearing knee high slouchy suede boots and a wizard robe (since I only do that while playing Dungeons and Dragons, I’m not a barbarian).
It has a free trial but you have to pay pretty quick. The coolest new feature, I haven’t tried yet, is a group function that allows us to sit together, virtually, wizard robes optional, in silence, and meditate. I set up a Hippo Education Meditation Group on there. I am the only member :). Feel free to join if you use the App.
Update: they are now offering anyone a free month trial so if you want to try it you can go here.
A few weeks ago I woke up with that strange feeling of health and energy that comes from the absence of discomfort. After an epic 10 day trip to Indonesia focused on surfing in an environment at times paradise-like and at times very polluted, I got slapped down for a week or so by a combination of jet lag and some sort of severely crampy GI bug. The first morning I woke up not feeling horrible, felt amazing.
So, feeling grateful, I started up the daily gratefulness journal habit again: What three things am I grateful for today? I usually can find a few at the top of my mind. Often they’re the same things as the day before. But, that day I had a bunch of them and I scribbled them down in rapid succession over a few minutes:
- My trip to the grocery story with my 4 year old driving a mini shopping cart with pure joy and a credible threat of ankle injury for the public
- My conversation with my daughter about tap dancing and dealing with the older girls and their opinions
- The town that I get to live in
- My surfboard(s)
- The historical existence of people deep enough to have discovered mindfulness and meditation
- The absence of malaria (there is some of that in Indo)
- The fact that we don’t burn trash on a widespread basis in the US
- The Hippo team who did not need me in the least while I was gone
- My mom who is preternaturally amazing and selfless
- Hearing my mom and my wife laughing in the living room together
- The gruff but clearly skilled interventional cardiologist who put a stent in my dad’s 90% arterial occlusion yesterday
- My old gray haired Labrador, Bronx, and his still wagging tail in the morning
- The pool at the big hotel I’m taking the kids to today, and…
All of those things flooded in with no searching. It’s not always like that but the absence of discomfort, or suffering, seems to have sparked it. At any rate, I appreciated it. And, I appreciate medicine, and my team at my own company, and anyone else who is dedicated to relieving suffering of any kind. It’s hero work.
(If you happened upon this post without reading Part 1, do that first.)
In my last post I nearly fell off my chair, barely avoiding typing in all caps. Let’s do some more of that.
What is good medical education?
- Good medical education is respectful of the clinician in all ways. It is respectful of their time by not wasting it, of their daily practice by providing utility to it, of their patients by helping them indirectly, of their humanity through an authentic human tone, of their soulful burden by providing community. Bad medical education is minimal-effort profiteering on the back of a 100+ year-old broken system with as little heart and soul as possible. It’s a time sucker, pretentious, and disconnected.
- Good medical education is up to date, changes with your feedback, and is created by great medical educators who are experts in the field. Bad medical education milks out of date material. It employs laypeople to create the education then pays a dispassionate doctor with a big title at a famous institution to attach their name to it, spraying rose scented car-freshener over piles of garbage.
- Good medical education is human. It admits when something is challenging. It looks for the learning pitfalls, acknowledges them as tricky little buggers, then targets them for vanquishing once and for all. Bad medical education presents complex topics as if everyone (but you) already understands; brushing past difficult material quickly for fear of being exposed as amateur.
- Good medical education gives us recommendations for the real world. Bad medical education speaks down to you and asks you to “consider” doing this or that without being bold enough to suggest a path.
- Good medical education is funny, deep, supportive, or scary… like medicine in general. It wears its emotions on its sleeves. It feels like having a drink with a friend. Bad medical education is made by committee and feels like it was created by a robot out of cardboard. It leaves you more stressed than it found you.
- Good medical education often has CME credit attached to it but that’s not why you’ll want it. Like time with your favorite professor during training, the education is the true reward, not some CME certificate. Bad medical education focuses on CME credit and takes you to a beach destination or waves a $1000 Apple gift card in front of you so you can write it off your taxes and learn nothing. Nothing wrong with the beach or a cheap iPad, but it’s not medical education.
- Good medical education has its eye on technology, design, and modern ways of delivering content. Why should online learning feel like 1992? Bad medical education sends you DVDs and thinks you’re too stupid to use the internet and too naive to demand a good experience.
- Good medical education holds itself to a higher standard and looks to lessons learned in other educational fields. Bad medical education is riding a 50 year wave of mediocrity and consumer apathy. It knows you’re busy, you might not have time to research all the options, and enough of us will buy the garbage to make a tidy profit.
- Good medical education is happy to show you what you are about to buy and offers a robust and simple look at it beforehand. Bad medical education hides the product or makes you email someone for a “demo”. Beware the pretty homepage that refuses to show you the real product.
This list could go on. But, it’s not news to you. You already know all this. We just have to change our expectations. Once it’s clear that we all demand better, the system will change. It is changing already. There are a lot of great educators out there waiting for a stage. CME can be something to look forward to instead of a hoop jump. We can all help ourselves out of the shame spiral of keeping up to date. We deserve better education. Let’s demand it.
Staying educated is different before and after training
My specialty is Emergency Medicine but I think the following sentiment applies to all clinicians: doctors, PAs, NPs, nurses, techs… the whole team.
Do you remember, in school or in residency, when you made a great diagnosis, did some cool procedure, or saved the day in some way? What happened next? High fives all around, proud mentors, stories at rounds, teaching peers how you did it, drinks after work… good times.
Remember the first time you did the same cool thing after training?
You looked around for your high five… crickets.
Nobody really noticed or cared all that much. No mentors, nobody to teach to or learn anything deeper from. It’s a stark contrast and it is super hard to get used to. For me, it was depressing, and the introduction to some of the negative realities of being an attending (done with training) clinician in the real world.
This website and blog is an experiment that I’m hesitatingly putting out there publicly. It starts here as a work in progress. I am not particularly confident in my ability to write well or interestingly. And, I don’t want to cultivate my own egomania.
But, even if just a place to highlight the great work being done at Hippo, it seems like a worthy endeavor. If you’re reading this (which still seems quite unlikely to me) then thanks for being here and please say hi in the comments (yes, even you, Mom).