A Tribute to My Mother, and Why I Write

My mother, Sandy Ying Zhang, is my role model and my inspiration for what I do every day. She was diagnosed with breast cancer when she was in her forties, and fought it courageously for seven years until she passed away in 2010.

My mother Sandy, father Xiaolu, me, and my sister Angela

There are so many stories I can tell about my mother and her battle with cancer. Let me start with just one. Whenever she’d go to her oncologist, she would go armed with a list of symptoms. To his credit, the oncologist was always good about giving her a working diagnosis that made sense of her symptoms. Still, though, she often called me to complain that she didn’t understand the diagnosis and how her symptoms could possibly be attributed to it. For example, she went to her doctor once because her stomach was hurting. He thought it was due to constipation caused by her “medications”, and asked her to take some stool softeners. She couldn’t understand why—if her “medications” were the cause of her problems, why was he telling her to take more of them?

I knew that what her doctor meant was that he suspected her abdominal pain was due to constipation, which was caused by the pain medications she was on—but either he didn’t explain this to her, or she didn’t understand what he said. “So why didn’t you ask the doctor about it?” I would ask.

She never had an answer to this, and it took me a long time to see her perspective—the patient’s perspective—about why she was so reticent. Asking her doctor questions just wasn’t something she thought she could do, and no amount of cajoling on my part could get her to change her mind. That didn’t mean she would eventually agree with the doctor; actually, she often disagreed, and often didn’t follow his treatment recommendations. Throughout the entire time she was ill, I didn’t understand the logic, and attributed her reticence to her having come of age in China. However, I didn’t quite understand, because she was a schoolteacher in some of the roughest parts of Los Angeles and never had trouble standing up for her students. So why couldn’t she advocate for herself when she needed it the most?

As a doctor, now, I see that my mother was hardly alone: many patients are genuinely afraid to challenge their doctors. And I don’t mean challenge the doctor as in pick a fight with them, but even to ask basic questions. When I talk to patients about their diagnosis, they tend to nod and agree with almost anything I say. Sometimes, they’ll ask a question or two; very infrequently does someone actually stop me and say, “Hmm, that doesn’t sound quite right”.

In speaking with patient advocates about this, it seems that patients think they would be rude or presumptuous to question a diagnosis, especially since they think they know so little. It’s quite the opposite: doctors should WANT our patients to ask questions and help us perform a final reality check! In my practice, I’ve taken to asking patients specifically if they think the diagnosis I had in mind makes sense to them, because it encourages them to bring up any concerns or questions. Not infrequently, these questions lead to a real breakthrough and really change their diagnosis and management.

My mother is my inspiration for writing this book because she had gone through many misdiagnoses: initially a missed diagnosis of cancer and then multiple other misses along the way, including, eventually, a missed diagnosis of pneumonia that led to her death. There is nothing I can do bring her back now, but she always believed that one person can make a difference. I want to make a difference to my patients and encourage all of you to make a difference in your healthcare. Speak up the moment you have a question, the moment you don’t understand something the doctor said. Don’t let more time—and more opportunity for misunderstanding—pass by. The work that you do will revolutionalize your interactions with your doctor, and potentially change how your doctor interacts with future patients as well.

For Students and Residents: a Guide to International Emergency Medicine

International emergency medicine (IEM) is one of the most popular subspecialties in emergency medicine. Among other medical specialties, international medicine is just as popular. As a senior resident, I have seen many a medical student or junior resident light up when I discuss IEM. But even though IEM is a great buzzword, it can mean different things to different people. Does it refer to a clinical rotation to see how EM is practiced in other parts of the world? How about developing emergency systems, or providing humanitarian relief? Where does research or teaching fit in? In my first president's column, I want to share my passion for IEM with you by providing some guidance and advice that I wish I had gotten when I was first drawn into IEM.

Unlike some of my IEM colleagues who were born to do international work, I had my heart set on a career in domestic health policy. It wasn't until medical school that I was exposed to international health. A fellowship at the WHO made it clear that the issues I was working on in the U.S. were magnified many times over in other countries. Geneva was an eye-opener, but I felt a need to work "on the ground", so went to Rwanda to do fieldwork on gender-based violence and subsequently to the Democratic Republic of the Congo and Burundi as a journalist reporting on war and health.¹ Through this exposure I saw the urgent need for research to understand systems and evaluate interventions, and decided to go to the U.K. for two years to study economics and policy. I came into residency with more tools and a stronger passion for IEM research. Now, entering my fourth year, I have conducted systems design and evaluations in several countries,^2-4 a healthcare workforce evaluation in South Africa,^5-7 and a global health professional study.⁸

Everyone’s path in IEM is different, and I share my background with you so that you can see my circuitous path in this journey. Students and residents often ask about getting involved with IEM and what things they should consider in building an IEM career. Here are some thoughts:

1) The only way to know whether or not you will like something is to try it. If you are new to international work, find an opportunity and jump on it. Don't be picky about location or type of experience. Many schools and residencies will have an international rotation. Most likely it is a one-month clinical experience, but occasionally it is a research project (e.g.,  studying malnutrition) or an educational opportunity (e.g., teaching point-of-care ultrasound). There may be a relief mission that needs your help. Some of my residency classmates went to assist with the disasters in Haiti and Japan. These were not things that they planned, but they jumped on opportunities that came up. Explore multiple options. Your own program is the most natural place to start, but also look elsewhere in your university. The American Medical Student Association has medical student elective listings. AAEM/RSA is also establishing an international rotation database. Keep your eyes and ears open and ask other residents and attendings to be on the lookout for you.

2) There has been a lot written in recent years about "medical tourism".^9,10 While this phrase conjures up unpleasant connotations, and sustainability in international programs is very important to think about, don't discount experiences because of your own (unnecessary) guilt. International rotations are important for your exposure, and whether you end up doing international work or not in your career, your experience will be instructive for you and good for your future patients. Find your own way to meaningfully learn and to contribute.

3) Once you’ve had experience with IEM, decide whether it is something that you feel passion for versus something that you would like to do only occasionally. There is no right or wrong answer--don't feel guilty if your experience showed you that you don't want to live in war-torn countries forever. Be honest about what you like doing and how you think international work will fit into your career. What attracts you most about the work? Does clinical work excite you while research bores you? Are you happiest doing impact evaluations from the comfort of your own home? Would you want to do these things occasionally, or do you love them so much that you need to build it into your career?

4) Consider the other interests that you have to balance. International fieldwork is hard to find time for in residency, but it might be even more challenging with a young family. Know how your significant other feels about your work. This is a continuing conversation for me and my husband, a South African native who I met in the U.K. Initially, we thought that we would spend two months every year abroad, but this is difficult to manage in both of our careers right now. It took me a while to realize that not everything I want has to be done at this very moment. Perhaps this is the time to focus on your family and your clinical work. IEM opportunities will be there when your life settles down. Perhaps later on, you and your family might consider a year or two abroad, or you may be able to take a job with greater travel flexibility. Think about how you want to balance your IEM interest at this point in time and be flexible to change.

5) Don't discount related work in the U.S. I have come full circle in this regard by starting in domestic health policy, falling in love with IEM, then coming back to U.S. policy. There are huge problems with access to care and health inequities in the U.S., and what you learn through your international experiences will inform your work here - whether it's in policy, advocacy, community activism, or your clinical work. Many international interests can be built into your domestic work and vice versa. If you have an interest in EMS, you can develop your expertise in the U.S. first and then do projects abroad. If you have experience with teaching mid-level providers internationally, you can design similar programs in the U.S. The options are limitless!

6) Build and nourish your network. Identify mentors as early as possible. Seek out those you admire and follow their career paths. Read their work. Ask for advice from those who have IEM careers and those who don't--their perspectives will be just as important for you. Women, it may help to find identify female mentors as women face a unique set of challenges. The Academy of Womenin Academic Emergency Medicine is a great resource, and this year it is offering free membership to residents.¹¹ Along the same lines, build your peer group. IEM is a small world, and your peers will encourage and inspire you throughout your professional lifetime.^8,12

As my mentors have taught me, a successful IEM career necessitates thinking outside the box—and keeping an open mind and open eyes and ears. Speaking of being open, now is the perfect time to get involved! Don't discount any opportunities. Now is the time to make a difference, in the U.S. and internationally, with our profession and most importantly with our patients.

References:

1. The New York Times. Two For the Road Blog. Available at http://twofortheroad.nytimes.com. Accessed 1 June 2012.

2. Wen LS, Oshiomogho JI, Eluwa GI et al. Characteristics and capabilities of emergency departments in Abuja, Nigeria. Emerg Med J. 2011; Nov 2. [Epub ahead of print]

3. Wen LS, Anderson PD, Stagelund S et al. National survey of emergency departments in Denmark. European Journal of Emergency Medicine. 2012; in press.

4. Wen LS, Char DM. Existing infrastructure for the delivery of emergency care in post-conflict Rwanda: an initial descriptive study. Af J Emerg Med. 2011; 18(8): 868-71.

5. Wen LS, Geduld HI, Nagurney JT et al. Perceptions of Graduates from Africa’s First Emergency Medicine Training Program. CJEM. 2012; 14(2): 97-105.

6. Wen LS, Nagurney JT, Geduld HI et al. Procedure competence versus number performed: a survey of graduate emergency specialists in a developing country. Emerg Med J. 2011; Oct 21. [Epub ahead of print]

7. Wen LS, Geduld HI, Nagurney JT et al. Africa’s first emergency medicine training program at the University of Cape Town/Stellenbosch University: history, progress, and lessons learned. Acad Emerg Med. 2011; 18(8):868-71.

8. Wen LS, Greysen SR, Keszthelyi D et al. Social accountability in health professional education. Lancet. 2011; 378(9807): e12-13.

9. Jesus JE. Ethical challenges and considerations of short-term international medical initiatives: an excursion to Ghana as a case study. Ann Emerg Med. 2010;55: 17-22.

10. Van Hoving DJ, Wallis LA, Docrat F et al. Haiti disaster tourism—a medical shame. Prehosp Disaster Med. 2010;25: 201-2.

11. Society of Academic Emergency Medicine. Academy of Women in Academic Emergency Medicine. Available at: http://www.saem.org/academy-women-academic-emergency-medicine. Accessed 1 June 2012.

12. Morton MJ, Vu A. International emergency medicine and global health: training and career paths for emergency medicine residents. Ann Emerg Med. 2011;57: 520-5.

Portions of the article will appear as part of the American Academy of Emergency Medicine's Common Sense magazine. I serve as the President of AAEM/RSA. These opinions represent my own and not of AAEM or AAEM/RSA.

Male/Female, Same/Different

I’m an eighties baby and a proud member of Generation Y. A child of two working professionals who came of age in China’s Cultural Revolution, I grew up with a strong belief in gender equality. Feminism and women’s rights were concepts that I took for granted. Nobody ever told me that there were things I couldn’t do because I was a girl. Because of the battles fought by the generations ahead of me, I grew up sheltered, believing that gender differences and the professional challenges associated with them were relics of the past.

My early medical training helped to shield me from the realities of the world. I went to a very supportive medical school, where several of our Deans were women and had regular networking session for female medical students. These sessions were so popular that some men in my class tried to form a “male-only networking group”—an idea that somehow had a different connotation. I can’t recall a single incident of favoritism in my preclinical years. In my clinical years, the biggest challenge was getting visiting consultants and my patients to see me as the medical student—not the nursing student or candy striper. I learned to wear my white coat everywhere, and to laugh when someone would refer to me as “that nice nurse”, or, at one point, “that Oriental home health aide.”

It was in the U.K. that I had my first and most significant gender battle. After medical school, I won the Rhodes scholarship and studied at Oxford for two years. In my subject, economic history, we were required to take a beginning statistics class—something I wasn’t particularly thrilled to take, having taught stats on the graduate level before. Our class happened to have all men except for Jana, a Bulgarian girl who was a mathematician in her home country, and me.

After our first exam, the Professor stormed into the room. He gave us a lecture on academic honesty, and then pointed at Jana and me. “What can you say to explain yourself?” he yelled. “How dare you cheat on your exam?”

Apparently, the two of us had received high marks on the test. The 20-odd men, on the other hand, did not do particularly well. It was unacceptable to this Professor that the women—and two foreign women at that—had somehow outscored the men. The only explanation he could think of for this was that we had cheated.

The incident got resolved quickly through our department, though the Professor’s only slap on the hand was to mutter a begrudging “sorry” to the two of us. Though this experience was a very small part of my overall (very positive) educational experience, it gave me a great deal of respect for all the women who came before me, who had to face discrimination like this every time they went to class or work.

It also gave me additional perspective on other gendered experiences. In my residency, a group of female residents and young faculty attempted to form a women’s support network. Some of our colleagues, both male and female, questioned why it was really necessary to have a women’s group. In this day and age, aren’t issues that are relevant to women relevant to everyone else? Is there really anything to be gained from a network of high-achieving women?

I’m not sure that I would have known the answer to this before, but my answer now--as I am completing my medical training--is a resounding yes. Here are just a few of the reasons why:

1)    Mentorship. Studies have consistently shown that drive, intelligence, and passion are necessary but not sufficient for success; behind every star performer is a star mentor. Women can and should have male mentors, but female mentorship adds an additional critical dimension and nuance. For those of us in academic medicine, I am a believer that we all need not just research and professional mentors, but personal mentors, too.

2)    Practical aspects of work-life balance. It is almost a cliché to talk about work-life balance in a discussion of professional women’s issues. I’m embarrassed to admit that I used to roll my eyes every time we talked about it. Now that I’m married and thinking about starting a family, though, I seek out these discussions with women who have also “done it all”. I want to ask them how and what they did. How did they structure their initial career? What were challenges that they faced along the way, and what are the lessons they have to impart?

3)    Unique demands of our work. One of my classmates got fed up with all the talks on work-life balance and famously said that she wants to cut out the life and just talk about work. After all, isn’t work what men talk about? She’s not wrong; there are unique demands of our work, particularly for high-achieving women who wish to be "do it all" for our families and fo rour careers. It’s important to have the space for such discussions.

4)  Advocating for system-level change. Anne-Marie Slaughter wrote a provocative article in the Atlantic about how women can't have it all, and how it takes a village to really empower women. Gender equity is not an issue of the past; a recent Journal of the American Medical Association study showed that women physicians still consistently earn less than their male counterparts.

 

At this point, I have come full circle: from being a millennium child with little sense of gendered experiences, to a feminist with an understanding that being a professional woman continues to yield its separate challenges and requires active work. There are systems-level problems that require systems-level solutions, but it has to start with each one of us.

I would love to hear your thoughts on this and other matters. Portions of this article appeared in the Academy for Women in Academic Emergency Medicine awareness newsletter.

Trapped in the E.R.

Danielle is a 20-year old college student at the New England Conservatory. She came to the ER because of a headache. When she woke up this morning, her head hurt badly. Her mouth was dry, and when she tried to get up to go to the bathroom, she felt like she was getting faint.

She attributed all of this to drinking too much the night before—normally she has one or two drinks when she’s out with friends; last night, it was her roommate’s birthday, and she did three or four shots and had a few beers on top of that.

“The last time I had a hangover was a couple of years ago, and I think this was how I felt then,” she says. “My roommate Jackie told me to drink lots of water.”

Throughout the day, she felt too nauseous to eat or drink. When the headache didn’t go away in the afternoon, she called her mother. She doesn’t have a doctor in Boston because she doesn’t have any other medical problems and still gets her yearly check-ups over the summer when she’s back home. Her mom convinced her to go to the ER to make sure everything was OK.

Every provider who saw the Danielle knew exactly what she had: a hangover headache. She received some IV fluids and was texting away on her phone. However, her doctors were following a “pathway”, a cookbook recipe for what happens when someone comes in with a headache—they needed to “rule out” a bleeding in her brain. Danielle got ordered for a CAT scan of her head. It was negative.

This was good news—or was it? Soon, she was being told that she needed to stay for a lumbar puncture: a spinal tap. The doctors began pulling out needles to put into her back. At some point, she excused herself to go to the bathroom. That was the last time she was seen: as far as we can tell, she escaped out the window of the bathroom. She left all of her clothes and shoes, and ran out in her hospital gown.

All of us can sympathize with Danielle. She was young and scared, and she didn’t want a procedure that she didn’t really need. Instead of a rational discussion with her doctors where she could make sure her story was heard and ask about the risks and benefits of testing, Danielle felt forced into doing something she didn’t want to do. She felt trapped—literally—by the doctors and nurses, by the hospital, and by the medical system.

We do not believe such an approach is conducive to good patient care. We believe in a partnership approach where decisions are made together, not simply based on worst-case thinking or mindless adherence to a depersonalized recipe. Danielle’s story is unfortunately far too common. We hear it every day single day, and we write our book to help Danielle and patients her so that they do not have to feel trapped--but are rather empowered--to take control of their healthcare.

The Shocking Google Search

Every controversial idea has its share of detractors. We've certainly had our share of criticism, one of which is that patients don't care that their doctors don't listen to them. Basically, does our book have any relevance--is the problem we're describing even a problem at all?

A quick google search resolves that one. Over 93,000,000 sites come up when I type in "when doctors don't listen". The websites run the gamut from Reader's Digest suggestions for getting doctors to listen to studies showing women and minorities are listened to even less to hundreds and thousands of narratives from patients about how they are not listened to. Patients who are confused and frustrated by their care. Patients who go through years of not knowing what they have and suffer the consequences. Patients who want a different way, because their current level of healthcare is just not working for them.

Is our solution the be all and end all to this problem? Probably not. But let's put to rest the argument that there isn't a problem with our healthcare system. Let's put to rest this concept that our patients are happy with the care they are getting. Now let's do something about it.

The First Post!

Hello and welcome to my blog! This is the site for my forthcoming book, co-authored with Dr. Joshua Kosowsky, entitled WHEN DOCTORS DON'T LISTEN: HOW TO AVOID MISDIAGNOSES AND UNNECESSARY TESTS.

Our book is all about how you have to take control of your healthcare to make sure that your doctor listens to you and gives you the best care that you deserve. We are E.R. doctors and were first inspired to write the book because we saw so many of our patients leaving the hospital confused and dissatisfied. Patients come to us with symptoms that are troubling them, and we are so concerned with "ruling out" potentially life-threatening diseases that their entire medical care gets focused on figuring out what they DON'T have. You have a belly ache? Let's make sure it's not appendicitis or gallstones. A CAT scan and some blood work and an ultrasound later, we are pretty sure it's not appendicitis or gallstones, but what do you actually have? So many unnecessary tests get done. So you leave without any better idea of what you have and how you can get better.

Our book is about how patients can advocate for their own health by doing one very simple thing: asking for a diagnosis when you go the doctor. You go to the doctor because you want to find out what’s wrong and how you can get better. In today's world, though, all you get are tests to “rule out” problems rather than getting to the diagnosis. Patients get huge bills with tons of tests, but at the end of the day, leave without every finding out the very reason they went to their doctor in the first place. We guide patients to help the doctor make a diagnosis. We show how to advocate for your own health and put the focus of medical care back on doing what’s best for you. We see our book as the beginning of a healthcare movement to empower all of us to take control of our health--and get the best medical care that we deserve.