One day in clinic, recently, I reviewed my daily schedule with the oncology fellows who were working with me that day. With the exception of the new patients on my schedule, I recognized all of the names on my list. I opened the electronic chart of the first patient to skim the problem list, a handy spot where I keep a summary of all the treatments received for the cancer diagnosis.
“Mrs. Jordan* is just here for routine follow up. She completed therapy about three years ago, and she’s done great so far,” I said. I went on to tell them that her son was a physician, but that he never came with her to her appointments. He had emailed, once, just to touch base; but it was clear that his mother valued her independence and wanted be in charge of her own health care. She was in her 80s and very clear about her expectations of me and, I’m certain, of her son.
Using the computer mouse, I pointed to another patient on the list.
“Ms. Finley is coming today to discuss her CT scan from last week,” I said.
I planned to discuss chemotherapy with Ms. Finley, and I was sure she would agree based on the scan results that showed progression of her cancer. I mentioned the regimens I was considering to the fellows, as well as my rationale for my top two choices. I fielded questions about chemotherapy selection in platinum-resistant ovarian cancer versus platinum-sensitive disease.
“She’s retired from teaching,” I told the fellows. “She usually comes with her daughter, who’s a pharmacist.” Keeping busy through volunteer work has been very important to Ms. Finley, and it’s helped to reduce her anxiety about her disease. I hoped she was still doing it. If she had stopped volunteering, it could be an indication of her level of symptoms.
I have a new post up on ASCO Connection, in which I profess my love of the social history. Here's a teaser, but you can read the full post here.
I have a new post up on the ASCO Connection site. To read the rest, head to the site.
"I just want to know that she'll be able to travel," my patient's husband said.
To read the rest, head over to ASCO Connection, where I've started writing a regular column. I'll be sure to continue to share here as well.
I received a fax recently, from the office of another hematologist-oncologist, at another academic medical center. Attached to the fax cover page, with my name and fax number scribbled in slanted script, was a five-page consultation report on one of my patients. That oncologist – I’ll call him Dr. Z – had seen and evaluated my patient to provide a second opinion on the patient’s diagnosis and treatment.
The lengthy report was thorough and well articulated, representing the Dr. Z’s skill in data gathering and documentation. The other reason the report was so long, though, was because of the templates built into the electronic medical record he used. I know this because my own template-driven consultation notes are exceedingly long, something I struggle with in using our own EMR. The meat of any consultation note, though, is at the end – in the assessment and recommendations section. In Dr. Z’s report, the recommendations took up the entire last page.
When I read that last page, I could feel my anger rising, along with my heart rate.
Dr. Z mostly agreed with my own recommendations to the patient, and while this is always reassuring, I would not have been offended if he disagreed entirely. I refer a lot of patients for second opinions, for a variety of reasons. Second opinions can ease a patient’s mind and provide reassurance, they can open up opportunities for clinical trial participation at other centers, and they can give another outlook on the case from a fresh set of eyes. While I love when someone agrees with my plan of care, I appreciate the art involved in the practice of oncology and that oncologists have different practice styles. For example, an oncologist with 20 more years of experience than I have can probably teach me something, and I always look forward to learning things that can help me care for my patients better.
This report from Dr. Z, however, was written with a tone that made me want to stop reading immediately. The report made me angry and mistrustful. He mostly agreed with my treatment plan, but he disagreed with some subtleties in the care I provided my patient. In those areas he disagreed, he made it clear in his recommendations that the “local oncologist should be” or “must do” or “should not do” this or that. His use of language was very dogmatic. It was clear in the way Dr. Z had phrased his words that he did not allow for any differing opinions or practice styles than his own. It was clear that he was right, and that I was (obviously) wrong. Unfortunately, this second opinion had not served my patient well and taught me nothing.
Or maybe it did teach me something.
I believe there is an art to writing a good consultation letter to another physician. Heck, it takes skills to write good letters in general. These are skills that we learn first as very young children, when we begin writing thank you letters for birthday presents and letters to pen pals. And, hopefully, we continue to learn these skills throughout the rest of our educational careers.
A good letter to another physician – such as the second opinion letter – should be respectful and polite, and it should convey information in this same respectful and polite tone. The letter should not be overbearing or bullying or inflammatory. It takes skill to write a good second opinion letter when there is agreement with the medical decision-making. It takes a greater level of diligence and finesse to write a respectful letter when there is disagreement.
I perform a lot of second opinion consultations myself, as many of us in academic medicine do. It goes with the territory of being a specialist. In the reports I write to other oncologists, I try to follow my own advice. If I disagree with a treatment plan, or with an aspect of care, or if I have an idea for a treatment that the other oncologist has not mentioned in his notes, I tend to use words like “could consider” or “an alternative could be” or “in my own practice, I sometimes use ___.” I thank the referring physician to allow me to provide this service, and I am polite from beginning to end, even if my opinion on treatment differs.
I write second opinion letters with the full understanding that in medicine in general, and certainly in oncology, there is not always one right answer. In fact, there are usually several accepted, evidence-based treatment options, and there may be many ways to administer and time those different options. I do not judge. Most importantly, perhaps, I realize that my second opinion is formulated at one moment in time, without the benefit of that amazing gift of wisdom: hindsight.
I first dipped my (professional) toe into the world of Twitter in January 2011. I’d already been using social media for personal reasons, but I wasn’t sure how using it professionally could be beneficial. I started slowly, following well-known news media (e.g., NPR Health, the New York Times), health organizations (such as the American Cancer Society, and the Leukemia & Lymphoma Society), and medical publications (Annals of Oncology and The Oncologist, for example). There weren’t as many oncologists on Twitter back then, but over these past three years, more and more have joined, created profiles, and become active users of the technology.
I’ve taken some time to reflect on social media and it’s use in medicine, and in oncology specifically. Yesterday, I gave a lecture to hematology and oncology faculty and fellows at my institution on the potential applications of social media in oncology. I’ve given a version of this talk before – several times, in fact – over the past couple of years. The questions from the audience continue to get better, and I can tell that more and more are interested.
And this is good, because social media isn’t going away.
I think we – physicians and health care providers – owe it to ourselves (and to our patients) to understand where are patients are finding support, finding guidance, and finding answers to health-related questions. And right now, more and more, our patients are finding this information online and on social media.
There are risks associated with using social media, and these potential risks stand as a barrier for many who might otherwise use social media. Physicians – and the general public – are often concerned about the risk of privacy violations, whether real or perceived. Health care providers have concerns for the potential for liability. We worry about the quality of information that gets disseminated online. There are worries about content theft and lack of proper attribution. Physicians worry about whether we can separate our professional and personal lives – and should we?
I focused a lot on Twitter in my talk yesterday, for this is my preferred social media application. As I wrapped up the lecture, I shared with my audience the 12-word social media policy from Farris Timimi, MD, the medical director for the Mayo Clinic’s Center for Social Media. His policy is so simple, and that’s why it’s nearly perfect: Don’t lie; don’t pry; don't cheat; can’t delete; don’t steal; and don’t reveal. You can read his original post here for elaboration on each of these.
One of the faculty members in the audience raised his hand.
“But aren’t these things our mothers should have taught us when we were kids?” he asked, already knowing the answer to his own question.
Yes. Absolutely. And I believe that if we follow that simple 12-word policy – or my own rule to never share anything that would embarrass or offend my own mother – what an amazing place Twitter could be…and, most of the time, already is.