Yes, ma’am, I see that your teenager has spent this entire appointment playing a game on his phone. No, that does not mean he is having seizures.
Why it’s important to have inclusive research leadership
I participated in the #ShutDownAcademia strike today. No research, no emails, no papers, no grant-writing. Instead, I spent the day reading The End of Policing and developing an action plan.
And I had a chance to put my action plan into action today.
The one research-y activity that I did not have the authority to defer, or the political capital to suggest deferring, was a site selection call for a multi-center study of mental health screening. We had a list of about 10 potential sites and had to pick 5, with a couple maybes for backup.
As we’re going down the list of sites, one of the other researchers on the call, an older man who mentioned during our intro/check-ins/small talk that he felt like he was relieving 1968, raised a concern that this particular site we were talking about (let’s call it the University of Middle-Earth) reported that about a quarter of their patient population did not speak English, and that the most common three languages spoken by their non-English speakers were, say, Quenya, Sindarin, and Dwarvish.
Older Man was concerned about whether the screening questionnaires would be available in those languages.
Some hand-wringing from others on the call about whether a 25% non-English-speaking crowd would be a disqualifier.
I unmuted.
“What those numbers suggest to me,” I said, trying not to get distracted by how TERRIBLE I look blown up on the Zoom screen, “is that the University of Middle-Earth is drawing from a very diverse patient population, and even among the 75% who do speak English, a substantial number of them may have Elvish or Dwarvish ancestry. And given that mental health concerns vary so much across cultures, I think that diversity is a feature, a real plus.”
Reader, we picked that site.
Not only that, but when a similar issue came up with another site (which reported about a 50/50 English to Spanish ratio — the screening questionnaires are definitely available in Spanish), the two white English-speaking principal investigators on the call both spontaneously said “We should definitely include this site, as [The Scrivener] said before, we want to make sure we have a broad and diverse representation of patient experience.” One of the PIs (whom I have worked with before and think is wonderful) even referenced the fact that, like, 99% of trials in our field are “lily-white” and that we owe it to the patient community to do better.
That’s how easy it is, friends. I spoke up, and it made a difference. Me, the shy little introvert, the one whose teachers would routinely send notes home saying “She should talk more in class.” And boom, two of our five sites have a substantial proportion of non-white patients.
It’s not good enough to just #ShutDownAcademia or #ShutDownSTEM. That’s step 1; steps 2 through eleventy-billion are #StandUp and #SpeakOut.
Quarantine Update
One week done, one to go. I remain afebrile and not coughing or short of breath. Perhaps all the aggressive OR-style handwashing and Purell dispensing worked!
The hardest thing about this is not seeing other people. I am an introvert by nature, but I never realized how challenging it is to literally not have a face-to-face conversation with another human being. Some of my work friends are going to stop by tomorrow evening so we can have a yelled conversation across the street. C’est la vie.
The other hardest thing is that I’ve had a lot of time on my hands to get angry at the abysmal government response to this plague. The surprise travel ban left both travelers and airports utterly confused and unprepared. Reports from IAD, DFW, and ORD of snaking lines, hours long, of standing cheek-to-jowl with others, some of whom looked visibly unwell. No temperature screenings. No information to travelers about what to watch for as they self-quarantine for the next 14 days. It was a shambles.
Make no mistake, thousands of people contracted coronavirus waiting in line at Customs and Border Patrol today. With the best published case fatality rate (S Korea, 0.8%) that means at least 100 excess deaths. Probably more on the order of 500. And every one of those deaths is a direct result of the president’s whimsy.
I’m really glad, after all, that my parents opted to delay their return another week. Hopefully by then CBP will have gotten their act together.
Love in the time of coronavirus
I have been quarantined for less than a day and it’s already terrible. Flew home from Spain on March 8 (Italy lockdown occurred while I was in flight); Madrid announced school closures on March 9 then public closures March 10; Schengen zone elevated to CDC Level 3 late on March 11 = automatic quarantine for me! I am doing what I can remotely and have asked to open extra clinics after March 23 when I am slated to return (assuming I remain asymptomatic), but I was already booked solid for weeks, so I don’t know how all these folks are going to be seen.
Still, it’s better than trying to power through and potentially infect my mostly geriatric patients. And I can always write a paper or design a lecture (or write a really long Facebook post) in my PJs. Honestly, the worst thing I have to deal with right now is remote Epic, which is a fail regardless of location. (I also made the terrible mistake of downloading an e-book of Daniel Defoe’s Journal of the Plague Year; do not recommend at this time.)
More frightening than Defoe’s mortality tables and creepy plague-sniffing witches, though, was the total absence of any kind of screening for returning travelers to the US. Admittedly before the travel restrictions were announced, but there wasn’t even a sign up in the airport about how to monitor for symptoms, as I’ve seen when flying during SARS, MERS, and H1N1. I’ve been operating under the assumption of exposure: hand-washing like I’m scrubbing in, and self-monitoring with BID temp checks since returning, but the 100+ other people on my flight, probably not. I have created a list of locations I’ve been in since my arrival, for contact tracing in case I wind up testing positive; the other 100+ probably not. My brother flew to IAD, one of the 11 designated special screening airports, and also nothing. I’ve cautioned him on the hand-washing, temp checks, and the need for contacts list, but how many other people have a physician sibling interested in epidemiology (and in not dying/accidentally killing others).
Speaking of epi, let’s do some back-of-the-napkin math. Nationally, tens of thousands of people transit through US airports daily, then go to work or school or restaurants. If even 10% of them are positive for coronavirus (extrapolating from the positive/tested ratio thus far), that’s close to 500k since the outbreak started at the New Year. Most of whom don’t/didn’t know they are carriers because they’ve never been tested. The reproductive rate seems to be 2.5-3 (that is, each infected person will go on to infect between 2-3 others), and the case doubling time is about a week, so… implementing a Schengen travel ban now is not so much closing the barn door after the horse has bolted. It’s propping up the barn door against a tree after the horse has gone on a rampage and torn down the damn barn.
So you can see how my thinking on this has changed in the last 72 hours. Hindsight being 20/20, part of me wishes I had canceled the trip, not because it would have necessarily saved me exposure — COVID-19 was hanging out in my city long before I got in an Uber to the airport, we just didn’t know it yet — but because it would have saved me 14 days of thumb twiddling quarantine and maybe I could have been of use to my department instead of being a drag.
Social distancing and so on are certainly important (hi Local Performing Arts Center, can you not be advertising $35 tickets for Les Mis this week?? THANKS), and I fervently wish we had implemented even basic public health education in January, but the move forward from here, in a health care setting if not across the board, needs to be universal precautions. Just like with blood-borne illnesses like HIV and Hep C, assume that a person is contagious until proven otherwise.
tl;dr Isolate, isolate, isolate. Wash your damn hands, cough into your elbow, don’t shake hands. Take your adorable little munchkin-disease-vectors out of school; minimize exposure to others. Best of luck, my friends!
Overheard in clinic
Undergraduate research coordinator 1: I wonder how old Dr. Stevens-Johnson is.
URM 2: I dunno, I think she looks younger than she really is.
URM 1: Yeah, at first I thought she was younger too. But then I heard she used to be program director, so she’s gotta be old. I bet she’s like, late 30s at least.
High-yield
“Is this high-yield for the exam?”
I was running a NeuroJeopardy review session for the clerkship students, and they were … not doing well. I always have them pick team names, and Team Gunners was at -1200 points (sigh), while Team Shelf Sucks was about twice that.
So one of the students on Team Gunners raised their hand and was like “Is this high-yield for the shelf?”
I looked her square in the eye and said, as monotone as I could muster, “It is high-yield for that moment when all that stands between your patient and death is you.”
And ok, that was a little dramatic (dramatic, who, moi?) but in medicine, and especially in neurology, that’s really really true.
I’m acutely aware of that this week, given major health crises in two far-away family members. One was a neurological issue, the other was not, but both required hospitalization and flirted with a potential bad outcome. Both, thank goodness, are doing fine, thanks to early recognition and treatment. I felt really terrible about one, because I had mentally misdiagnosed my family member based on hearing about their symptoms over the phone. Luckily, someone else, on the ground, thought about what else it could be, tested for it, and identified the right disease. If you don’t think about it — and I hadn’t — you won’t get it right.
When all that stands between your patient and death is you.
How do you get students out of the “study for the test” mindset and in to the “study for your future patients” mindset? I really struggle with this, as an educator. It doesn’t help that medical training involves a series of difficult gate-keeper tests, and therefore selects for exactly the wrong sort of incentive. They know the buzzwords, like “pill-rolling tremor,” but when I point out that a patient isn’t going to say “I have a pill-rolling tremor,” when I ask them to show me what a so-called pill-rolling tremor might look like, they ain’t got nothing.
Medical students reading this: Never ever EVER ask your attending if something is “high-yield.” This is a profession where other people live and die and suffer or not by whatever you manage to cram into your noggin. It’s all high-yield, and if you can’t stand that kind of heat, hop on out of the fire.
MDS 2019
Last day of the 2019 Movement Disorders Congress in Nice today. It’s really only a half-day, which allows for some time to explore the city a bit — much appreciated, as other days have run from 8am to 8pm, and last night’s Video Challenge ran till 10:30! Very glad I opted for an Airbnb across the street!
One of the great things about these meetings is the chance to catch up with friends and former colleagues. Being in a gorgeous city, like Nice, definitely helps. I’ve been able to go out to lunch and/or dinner with some fantastic people, in fantastic settings, and the food has been uniformly excellent.
What is it, though, about Americans abroad? I’m perhaps more acutely aware of this as I lived in Grenoble for a month as a resident (one of the best experiences of residency!) but so many Americans behave horribly in restaurants. It sounds cliche, but it’s true! People just wander around, sit wherever, don’t greet the servers, complain about the lack of substitutions on the menu (dude, the chef is a highly trained professional and knows way more about food than you do!) and servers not speaking English. People also complain about a notable frostiness in service here, but it doesn’t have to be that way! The French are some of the warmest people I’ve ever met, but they are also the most dignified, and to paraphrase a character on the hilarious Australian show The Librarians, “Their country, their rules.”
So, what are the rules, anyway?
In France, when you enter a restaurant or any other space, the VERY FIRST THING you must do is call out a cheery “Bonjour!” (Or “Bonsoir” if it’s after 5-ish.) Even if you don’t see anyone — the shopkeeper or the head waiter is probably in the back. That single word, even if you don’t know any other French, will get you better service. It shows that you have respect for the shopkeeper, server, whatever, and you are meeting them as equals. I do this reflexively everywhere except Lidl, the discount grocer with the East German vibe.
If you speak French, speak French! It’s so much easier to get your point across, and people will love you for it. Otherwise, apologize for your poor French and ask if English is ok. (“On parle anglais, s’il vous plait?”) It’s quite likely that your server will speak English, especially if you’re in a bigger city, but just make a small effort, for God’s sake. (Of note, Americans who complain the loudest about people in France speaking French are usually the same Americans who insist that everyone in the US must speak English. The degree of cognitive dissonance is stunning.)
And lastly, when you get the bill (“l’addition, s’il vous plait”) you don’t need to add an extra 30-40% to the bill for tax and tip. C’est tout compris! Unlike in the US, servers in France make a living wage, so the price you see on the menu is the price you pay. (Note: this is also why Americans think French servers are distant, because they don’t have to come to your table every 3 seconds asking if everything is ok/begging for tip.) Of course you can leave a bit extra for excellent service, but it’s not a requirement — that may be changing as more Americans go abroad and just assume everything is like it is at home. I was kind of annoyed earlier this week when I went to dinner with a large group, and at the end of the meal, the price per person for our prix-fixe dinner, according to the organizer, had gone from 35 euros to 50. (We’d ordered some wine for the table, but still! Not 200 euros worth of wine!) But we had behaved abominably, and I felt really bad for the servers, and it was getting late, and I didn’t want to wait for the server to bring the actual bill + credit card machine, so I just left cash and walked home, mentally calling the extra 15-ish euros my Uber fare.
So there you go. Three simple rules for getting excellent service in France. It really boils down to one core concept: treat people with respect, and they’ll treat you well in return.
How to interview someone, and how to not.
I am waaay behind on podcasts, and just listened to the Fresh Air interview with Robert Caro, author of the 4-volume LBJ biography. It was sort of meta and recursive, listening to an interview about interviews. I’ll be honest, I have zero interest in reading the LBJ biography, partly because I find little value in celebrating the lives of Great White Men who lived in an era that was even more misogynistic than our own.
But one thing really struck me about the Fresh Air take. Toward the end of the interview, Caro talks about how he was reticent to discuss LBJ’s numerous extramarital affairs, purportedly because he didn’t want to embarrass Lady Bird Johnson, who was still alive at the time. But one of these women, Alice Glass, apparently played a big role in the Johnson presidency, and writing about her and the affair would be unavoidable in a comprehensive biography.
So Caro tells Fresh Air’s Dave Davies (“in for Terry Gross”) that he received a summons one day from Lady Bird Johnson to come to the ranch, where, “without preamble,” she started telling him all about Alice Glass and how much she admired this woman who did so much for her husband’s presidency. Caro tells Davies that he took copious notes and then went home and wrote whatever it is he wrote about Glass. And that’s the end of that.
It’s shocking to me that neither Caro nor Davies press the point further. To them, it’s an anecdote about how Lady Bird Johnson ignores whatever her own personal pain must have been in favor of what was good for her husband’s career; isn’t she a good little wifey? To me, it’s just the opposite — it’s an anecdote about a woman who had very little explicit power of her own (I mean, even the nickname Lady Bird, which is the only name I and most others know her by, is infantilizing), is almost literally dictating the terms of how the world is going to read her husband’s mistress. Neither Caro nor Davies seem to consider that Mrs. Johnson might be an unreliable narrator, that she might have an agenda of her own. I can’t help me think that if Terry Gross had been conducting the interview with Robert Caro, it would have gone in a very different direction.
And that’s not unlike what it’s like to take a medical history, to be honest. You have to be willing and able to to question why a person is telling you what they are telling you, and to ask about what they might not be telling you. I work with students a lot, and most of them either take the patient’s story at face value (reporting rather than interpreting) or will hinge on something like a disability claim and declare that the patient is out for secondary gain and must be malingering. It takes an understanding of how stories work to realize how to pick apart the loose strands and reshape them into a medical note.
Currently reading: Mudbound, by Hilary Jordan, a decade-old novel that is oh so good. Talk about multiple perspectives! Haven’t seen the movie yet, but it stars Carey Mulligan so it’s sure to be excellent.
To conference or not to conference?
Like most academics, I get a lot of invitations to random conferences. They are usually pretty scammy, like Greetings, Fellow Doctor! We read your recent article with great interest and wish to invite you to talk on a subject of your choosing at our coming conference in Barcelona Spain, in August 2019. Please reply immediately if you wish to seize this remarkable and unforgettable opportunity!
taxpayer dollars on conferences
To be fair, legit conferences do this too, with reminders about registration and abstract submission deadlines. I flag the ones I’m interested in, and ignore the rest.
So when I got email reminders about an upcoming well-known conference in my field, I didn’t think much of it.
Then about a month ago, I got an email about CME (continuing med ed) disclosures. Huh, I thought, and moved on with my life.
Then, this morning, I got a link to upload presentation files. Hey, wait a minute!
So I logged in to the conference website, and there I am! Listed as a speaker! On a panel talking about a topic I actually know a lot about!
but the sentiment is the same
So then I really freaked out. Started combing through my emails to see if I had missed an invitation or worse, had responded to an invitation without realizing it. I know one of the other panelists so contacted them asking if they had nominated me (without checking? that would be weird?) or if they were blindsided too. Found a hotel room on Booking.com (free cancellation!) and started looking at flights.
But it still all feels really weird. I was not planning to go, before I got this email today. It’s a very well-regarded conference in my field, and an invited talk, even on a panel, would be fantastic for my CV. But the location’s kind of a pain to get to, and it’s coming in the middle of a very busy season — I’ll have just gotten back from one overseas conference, then I have two (local) talks scheduled, then am prepping for another conference just after this one.
What do you think, Gentle Readers?
The Most Wonderful Time of the Year
So, July 1 came and went with a minimum of fuss. For those not in the know, July 1 is the start of the new academic year in medical training, that day when all the fresh-faced young interns, who just spent the last 4 months (since Match Day) slacking on the beach, are suddenly tasked with Being A Doctor.
I vividly remember my July 1, walking toward the mirrored glass doors of the hospital in my new long white coat (freshly laundered: first, last, and only time it was actually white) and thinking, Who’s that doctor coming toward me so fast? and then realizing OH WAIT THAT’S ME.
My other big July 1 memory is when I was walking down one of the hallways and they announced over the loudspeakers “Rapid Response to the angio suite,” and some lady in street clothes grabbed me and was like “What does that mean?” and I, having just sat through hours of orientation, unthinkingly parroted “It means someone needs CPR,” and the lady just collapsed in from of me. Like she just fell to the floor in tears.
July 1, as an attending, is a little different. It’s more of the same old, same old over in clinic; we do have a fellow this year but she is off-cycle. But the other thing about July 1, or summer more generally, is that it’s application season! I read medical student applications last summer and probably will again, but in the meantime, am going through applications for the upcoming fellowship crop. And ye gods, they are making the SAME MISTAKES on their damn personal statements. I feel like I’m in Groundhog Day.
So, in the interests of trying to make things better for next year (sigh), here’s the Scrivener’s Top Five Tips for a Winning Application Essay.
Off-White Coat 