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It is no surprise that most doctors don’t feel comfortable talking to our patients about sex. We spend all of our 20s studying instead of experimenting! We even put it in the vice section of our history taking with smoking, drugs and alcohol. If should be grouped with questions about living situation, hobbies, occupation, and physical activity. It should be discussed as if it is one of the most important things in life. It is! Without it, life can’t continue! Addressing Sex as a Vital Part of Healthcare If is a very useful topic of discussion because it can be a barometer for cardiovascular disease and mental health and a motivator for addressing those issues, like smoking cessation or vaccination. If it for us to facilitate the ability to have the sex the patient wants to have. We should be asking questions like, “Do you currently have a partner? Do you have sex with men, women, or both? Do you have any questions or concerns about libido, arousal, orgasm or pain? If you show interest, confidence, and competence, patients will open-up about this. It also goes a long way towards building a relationship of trust and respect. Bridging the Orgasm Gap: A Physician's Role in Sexual Health This discussion wouldn’t be complete without bringing up the orgasm gap. The gender pay gap is often discussed, but the orgasm gap never is. Men orgasm in 95% of sexual encounters whereas only 65% of women do. Women usually only orgasm from clitoral stimulation which doesn’t happen in penetration. This is something for us to keep in mind for ourselves, our partners, and our patients for more equitable sexual satisfaction. Should we really be discussing this with our patients? Of course! Better us then social media influencers!

In order to be a successful physician entrepreneur, we need to cultivate skills we have not required in our training. For instance, selling. We are not practiced at selling our skills and expertise in exchange for money. We may be skilled at persuasion, needing to convince patients of a diagnosis or the importance of taking medication, having a procedure, or lifestyle changes, but it is very different to convince someone to part with money in exchange for our services. The first person we need to convince is ourselves. We need to believe in our own values first. We know that we have a very high-value skill set. We need to learn to be able to appropriately financially value those skills. Networking is another business skill that we are not taught, but is required in business. While we are in training, we are building our networks without realizing, but afterwards, it requires more effort. Networking is about cultivating relationships, and it should be done in such a way that it is enjoyable. The joy comes from the relationships being meaningful, not transactional. Expand your network through service and flattery – try to think of how you can be of service to others. Be respectful and stay curious. Also, flattery will get you everywhere; if you read someone’s book and it helped you, let them know. Some of those emails will evaporate into the ether, but some may lead to worthwhile relationships. Another way to network that may feel unsavory is the “pay to play” networking events that have admission fees. In the business world, these are high value events with high value people; just as we need to appropriately value our time, these networking events are often appropriately priced for the return on investment; you can create connections that are worth the price of admission. You are not paying someone to be your friend; you are paying someone for the value they provide. Physicians can also be intra-preneurs, where you bring your business skills to your workplace in order to help make it a place where you and other physicians can thrive. This can apply to negotiating pay, call, mid-levels to help with the workload, coaching services, etc. Another lesson that private practices can learn from the business world is leveraging email. We collect email addresses from patients, but are reluctant to use them. Businesses treat their email lists like gold. It is a way to keep your practice top of mind, keep the schedules filled during slower seasons, and inform patients of changes at the practice. Play offense. As we are building our businesses, it is important to keep the end goal in mind – selling the practice. That might not be your goal, but a business worth selling is also a business worth keeping, so it can help guide decisions.

Social media and even traditional media like print and broadcast media, are often a wealth of information and misinformation. Often the media works against the best interest of the population at large, because they are funded by advertising, which means if something is going to attract more attention, they are more likely to run it, and discuss it, even if it is based on misinterpretation of information. An example of this is when the World Health Organization (WHO) stated that countries with limited resources may want to prioritize other vaccines over the SARS-CoV-2 vaccine. This was interpreted by some media outlets as the WHO not recommending the Covid vaccine in children. This is a gross and often deliberate misinterpretation, which leads to more attention for the news outlet, and therefore advertising revenue. There are logical fallacies used by the media to garner more attention. Logical fallacies are based on shortcuts our brains take in order to decrease our cognitive load and draw conclusion quickly. This is an efficient way to process information, but in logical fallacies, these shortcuts backfire and leads us to incorrect conclusions. Sometimes a little kernel of truth can hook the reader, make an incorrect conclusion seem reasonable and then make the consumer more susceptible to larger more profound, incorrect ideas. Example would be that onions have anti-microbial properties, which gets distorted to “wearing onions on your feet can improve the function of the immune system.” Another common deception is the utilization of buzzwords that have no clear definition. Using words like “clean” or “natural” have no scientific meaning, but can increase sales by preying on the consumer’s fear of manufactured goods. This dovetails into the appeal to nature fallacy, where anything that is “natural” must be better than anything manufactured. Patients ultimately fall prey to misinformation and pseudoscience, because they are marketed very effectively to an audience who are often in a desperate situation; in that desperation, they are more easily misled. The marketers will use confirmation bias, leveraging the belief that medicine is bad, or that pharmaceutical companies are evil, to increase the sale of their product. They then use the hasty generalization fallacy to take a poorly designed, small, cohort study, or an animal study, and extrapolate it to mean whatever they need it to mean.

Positive medicine is the science of positive psychology, or well-being and flourishing, brought into the healthcare space to help providers live our best lives. It is not enough to address burnout. We need to work towards maximizing our potential in improving our abilities to handle life when it is going well, we will be more prepared when adversity inevitably occurs. This all seems very abstract and intangible. How do you even begin to define well-being and a life well-lived? Physicians Jordyn Feingold, MD, and Sanj Katyal, MD, both of whom have master’s degrees in positive psychology, developed a framework for this with the acronym REVAMP: Relationships, Engagement, Vitality, Accomplishment, Meaning, Positivity The first, and possibly the most important, is the strength of our relationships. The quality of our relationships is one of the best predictors, if not the best predictor, of longevity. A hill is perceived as less steep when looking at it with a friend, but this category isn’t limited to our friends and family. These include both personal and professional relationships. Less intuitively, it also includes our relationships with ourselves. This is a distinct relationship and one worth cultivating. In healthcare, we also have relationships with our patients, and when perceived as such, can be beneficial to both patient and caregiver. Engagement refers to being one with our day-to-day tasks; it could also be referred to as mindfulness (although then the acronym wouldn’t work quite so well). Mindfulness is covered in much more detail in a separate blog post, but suffice it to say, being present, in the moment. A wandering mind is an unhappy mind. Vitality refers to your physical health, but this isn’t just about physical activity in the form of exercise, but finding more ways to integrate physical activity in your life, and even realizing that some of the physical tasks that we are doing already are actually helpful for our well-being. Accomplishment or achievement can be as challenging to define as well-being. For each person, the definition will be different. First establish a set of values and then this can be used as a framework for defining success. Even if having lots of financial success isn’t in line with your values, financial achievement should still be included in this. It isn’t necessarily measured by the ability to purchase goods, but rather having a handle on your finances, and a reasonable financial plan. Financial worry can undermine well-being. Meaning – there is some overlap here with accomplishment and relationships in that it is important that there is meaning to our careers, meaning to our relationships, but this also helps us overcome adversity. When adversity inevitably arises, it is critical to our well-being that we can find some meaning there, too. This is best illustrated in Viktor Frankl’s Man’s Search for Meaning. As a psychiatrist and Holocaust survivor, he saw that the other survivors with the best psychological recovery from such horrific trauma were the ones that were able to find meaning and purpose in their day-to-day existence among the atrocities they were experiencing. Clearly, this is extreme example, but illustrates the point so we can find meaning in adversity. We can help our patients do the same. We can help them find post-traumatic growth. Positivity is a generalized affect or state, or finding ways to focus more on the positive and less on the negative. Remember... REVAMP: Relationships, Engagement, Vitality, Accomplishment, Meaning, Positivity. Each of these aspects are critical, and none alone are sufficient for well-being. Want the audio version? Here you go!

During her emergency medicine, residency, Alin Gragossian, DO, MPH, went into heart failure. A few weeks earlier, she was healthy, with a little bit of a cough, and the sniffles, and as she put it, “I was running the week before I went into cardiogenic shock.“ Suddenly, she found herself in the intensive care, unit of her own hospital, being cared for by her friends and colleagues. At that point, her ejection fraction was estimated to be 5% and she was in need of a heart transplant. Fast forward to today, Dr. Gragossian has finished her critical-care fellowship, and now shares her story far and wide. Being a physician so early in her training that suddenly became a patient in such a dire medical situation gives her a perspective that not many of us have.What she learned from being a patient can help us to be better physicians. One of the points that she makes was when she was getting wheeled back into the operating room to get her heart transplant. Although she has been realizing all along that this was a potentially fatal condition, and would be fatal without an urgent heart transplant, that realization really hit home when she was being wheeled back to the operating room at 2 AM to get her transplant. She realized that she could die on the operating room table. And she shared this with her mother. “I said ‘mom, what if I die?’ “She said the best thing a mom could ever say. “‘You could have died so many times up until this point and you didn’t. You are going to be fine.’ “That’s what I needed to hear.” Sometimes, when we are discussing risks and benefits with our patients, we get mired in what we are supposed to say. Sometimes, after we’ve had the risks and benefits discussions, and the patient is about to have a surgery or a procedure, to soothe their anxiety, would it be OK for the physician to simply say, “everything is going to be OK.“? If the patient has a complication and everything isn’t OK, does that mean we were misleading them? I don’t know the answer, but it would seem a hand on the shoulder, a calm demeanor and the words “everything is going to be OK,” might be just what the patient needs to hear. Something else that Dr. Gragossian learned from her time in the intensive care unit is that you hear everything! Sitting in a hospital bed without much to do, you do a lot of listening. You hear the different providers talking to each other about you, about the other patients, and maybe if you are lucky, spilling some tea about some hospital romances. The point here is, assume you are in earshot and keep it professional. When Dr. Gragossian was in the hospital, her parents were by her bedside every night. Her recollection of a lot of the events is spotty given how sick she was, but her parents remember everything. She makes the point that it is critical to check in on the caregivers, make sure that they are understanding everything, make sure that they are in the loop. Also, take every opportunity to check in on them and thank them. In her particular situation, where they were many different teams with different goals, it was hard for her parents to understand why the ICU doctor was happy with the fact that she was stable. If they were so happy, why did she still need a transplant? This illustrates why it’s important for each team to communicate with the patient and the caregivers the specificity of their role and what their goals are for the patient, especially if it might seem like the goals of one team contradict the goals of another team. She recommended that one team do most of the communicating so that the patient and caregivers get the plan in one cohesive way versus bits and pieces. She also stressed the importance of communicating the dynamic nature of decision making where new information leads to changes in the plan. To an outsider, this may seem like contradiction and indecision, which could shake their faith in their providers. We also discussed how in her situation, social media was amazing and wonderful. She found a community online of other heart transplant, patients who look and sound like her. Young professional women who could help her answer questions like “what is dating like with a heart transplant?” This isn’t something an eighty-year-old man with a heart transplant would be able to help her with. And one final piece of advice learned the hard way: don’t chug ginger ale right after being extubated.

Finding specialists that want to live in rural America is exceedingly difficult. Only 20% of Americans live in rural areas; 80% of rural areas in America are medically underserved. At the same time, rural towns are not large enough to support full-time specialists. The solution for this is telemedicine, but not exactly. Telemedicine is great for a lot of problems, but often the patient needs to be examined or procedures or infusions. This is where is the concept of a fractional doctor comes in. The concept of a “fractional” professional is common in business, but new to medicine. If your company is too small to need a full-time CFO, you can hire a fractional CFO to work part-time. They probably are the CFO of 9 other similar sized companies. Fractional physicians can manage patients remotely, but when the patient needs to be examined or requires an intervention, that is when the physician must travel. In person patient care can be consolidated to a single day or few consecutive days and then the physician returns home. This way, it is the same practitioner that develops the relationships with the patients rather than a rotating cast of providers. The part-time nature of the work and flexible schedule will be appealing for some physicians. This also helps the local hospitals who haven’t been doing well in rural areas because it keeps the outpatient procedures, labs, imaging, infusions, etc. local, which is critical because that drives a lot of revenue. The founder of this concept is ophthalmologist Kara Hartl, MD, who came up with this while working in rural Alaska. Clearly, this is beneficial for the patients because it brings specialists to rural areas and increases access to care. It is good for the doctors because it gives them some autonomy to work outside the systems that they normally do, another income stream, and work that is very fulfilling. Dr. Hartl’s company, Troy Medical, also tries to minimize pain points for physicians and patients by handling admin work for physicians and helping patient navigate the healthcare system. Is fractional doctoring right for you? Dr. Kara Hartl, Founder of Troy Medical

In medicine, we tend to make complex decisions, and it can be challenging to communicate how we were going about making those decisions to the patients. While we are talking to the patient, we are also actively making decisions which require a significant cognitive load. Often, the more complex the decision making, the more we end up speaking for ourselves, and not for the patients. We are trying to justify our decisions to the patients and are also justifying them to ourselves in real time. Once you realize that all of this is happening, it is important to zoom out and reflect on your own communication and make sure you are speaking for your audience and not just to your audience. Given that many of us treat the same conditions over and over, we have ways of explaining complex ideas with patients that we have honed and modified over many visits, and it gets to a point that it does not change very much. This is an advantage in that it decreases our cognitive load. It is important to realize that that extra cognitive energy that has been freed can be utilized to read the room, making sure that the audience is understanding, and changing the course of the discussion as needed. We need to develop this awareness so we can be nimble in our communication. This freeing up of cognitive energy by developing our discussions, or spiels, to use a Yiddish term with no equivalent term in English, is something that has evolved in humans because we have finite cognitive energy, so we need to protect it. We are cognitive misers. In order to conserve that cognitive energy, we develop biases and heuristics from our training, experience, and continued education. Sometimes these biases can be disadvantageous. This is discussed in other blog posts. In medicine, we use them to solve problems quickly. As we go through our training and gain experience, we identify patterns, which allow us to make diagnoses and treatment decisions much more rapidly. Sometimes there is no ambiguity about the diagnosis and management. The challenge is recognizing when we may be jumping to conclusions too quickly. Is there more data that may challenge our diagnosis? In that situation, it is important to order that extra lab test, imaging study, or send the patient to see that consultant in order to make sure that you are not relying too heavily on heuristics. It is also important to communicate with the patient the uncertainty of some diagnoses so that it leaves the door open for them to follow-up. Would we be open to changing the diagnosis if it were challenged? The IKEA effect is when we overvalue our own work. We will want to sell a product for more money if we put it together ourselves, like IKEA furniture. The same applies to a diagnosis. If we put in the work to assess a patient, we tend to overvalue our own conclusions. We need to be ready to recognize when we are incorrect and course correct and explain all of that decision making to the patient, which is more easily done if we’ve been effectively communicating uncertainty along the way.

In medicine, the process of decision making is often complex and multi-faceted. Healthcare professionals frequently find themselves facing challenging choices while simultaneously trying to effectively communicate these decisions to their patients. This can pose a significant cognitive load as they navigate the intricacies of medical decision making. However, the complexity of these decisions should not overshadow the importance of ensuring that the information is conveyed in a manner that is understandable and relevant to the patient. Decision Making in Medicine: Balancing Complexity and Communication While physicians are engaged in conversations with patients, they are simultaneously engaged in active decision making. This cognitive juggling act can make it difficult to effectively communicate the reasoning behind these decisions. In fact, the more complex the decision, the greater the tendency to speak for oneself rather than for the patients. Physicians often find themselves justifying their decisions to both the patients and to themselves in real time. Realizing that this multifaceted process is at play highlights the need to zoom out and reflect on our own communication styles. It is crucial to ensure that we are speaking not just to our audience, but for our audience as well. Striking the Balance: Adapting Communication to Fit the Context Within the medical field, healthcare professionals frequently encounter similar conditions and develop effective ways to explain complex ideas to patients. Over time, these explanations become refined through repetition, resulting in a decreased cognitive load for the healthcare provider. While this advantage allows for a more streamlined decision-making process, it also frees up cognitive energy that can be redirected towards reading the room and assessing the level of patient understanding. It becomes essential to develop strategies during these interactions to maintain awareness and ensure effective communication with patients, caregivers, and colleagues. This cognitive energy conservation, achieved through honed discussions or "spiels" (a Yiddish term with no direct English equivalent), is a natural response to our finite cognitive resources. As cognitive misers, we develop biases and heuristics to conserve energy. In medicine, these biases often serve as valuable tools for quickly solving problems. Through training and experience, healthcare professionals identify patterns that enable them to make rapid diagnoses and treatment decisions. However, there are instances when patients present with symptoms but without significant examination findings, such as in cases of classic migraines. In such situations, physicians rely on the heuristics and patterns they have developed over time. Yet, it is important to remain vigilant and recognize when a conclusion is reached too hastily. Could there be additional data that challenges the initial diagnosis? It becomes crucial to consider ordering further lab tests, imaging studies, or consulting with specialists to ensure that reliance on heuristics is not excessive. Furthermore, effectively communicating the uncertainty of certain diagnoses to patients leaves the door open for appropriate follow-up. Physicians must also be willing to acknowledge and recognize their own uncertainties. It is easy to fall victim to the IKEA effect, where one overvalues their own work. Similar tendencies can arise when physicians become overly attached to a specific diagnosis they have diligently assessed. Being open to the possibility of being incorrect and making necessary course corrections is vital. Equally important is the ability to explain the decision-making process to the patient, fostering trust and understanding. Embracing Uncertainty: The Art of Course Correction Navigating the landscape of medical decision making requires acknowledging the inherent uncertainties that can arise. It is not uncommon for patients to present with ambiguous symptoms or complex diagnostic puzzles. In these instances, healthcare professionals rely on the heuristics, patterns, and knowledge acquired through training, experience, and continued education. However, recognizing when the reliance on heuristics may be leading to premature conclusions is key. It becomes crucial to seek additional data, such as laboratory tests or imaging studies, to ensure a comprehensive evaluation.