Michael Hebert's Open Salon Blog

Why All Doctors Should Wear Bow Ties

Mon, 28 May 2012 12:05:50 -0400

When I was in medical school, ties were required on all clinical rotations. Ties for men, equivalent dress for women. Even in surgery we were expected to remove our surgical scrubs and put on a dress shirt and tie before we rounded on the floors. It was a discipline I thought all medical students learned. When I graduated, however, I discovered that either all schools didn't teach students to wear ties, or the discipline was quickly unlearned as soon as young doctors left medical school.

To me, a tie is part of a doctor's identity, helping us stand out from the crowd in the hospital environment. About a decade ago, when my father did patient satisfaction surveys for hospitals, he found that one of the most consistent complaints was that patients couldn't figure out who was talking to them. In a hospital, everyone wears scrubs, including doctors, nurses, physical therapists, phlebotomists, and even housekeeping and transportation personnel. This can make it very difficult to tell who the person is standing at your bedside in aquamarine scrubs. Yes, people introduce themselves, but usually only once. If you meet ten different people over the course of a single hospital day, which is easily possible, you will quickly forget who is the nurse and who is the respiratory therapist -- especially if they are wearing similar clothing. In our efforts to make society egalitarian, we've succeeded in making everyone look alike, even when their roles are not.

That is one reason for doctors need to dress better. It makes them easy to identify. This puts a patient at ease and relieves her from having to rack her brain for a name and a title, at least when the doctor enters the room.

Although I would hardly call myself a fan of haute couture, I do think fashion has value. Clothing isn't simply protection from the wind, any more than food is just processed nutrients. Clothing is a language, a form of communication. And like many forms of communication, its nuances are being lost in modern life. Our insistence on casual living may make day-to-day life more comfortable, but what we lose when everything is kept informal is the more sophisticated touch formality confers. If you show up at a friend's door for dinner in a coat and tie, it says a great deal about what you think of the occasion -- and of the friend. But that custom is gone with the Edsel, and with it went an opportunity to pay another person a compliment. Personally, I think it's a shame that most people consider a dinner guest who shows up in a coat and tie to be off-puttingly stiff, instead of what is really intended -- respect, appreciation, and consideration.

I started wearing bow ties in my clinical practice in 2003. Before that I always wore neckties. I made the switch for two reasons. The first was that the long necktie would often get soiled in the course of my work with patients. The second reason was that I thought the bow tie was an offbeat choice for neckwear, and yet more in the conservative southern style of dress, which I happen to like.

One of the interesting things about bow ties is that they can be both formal (think tuxedo) and whimsical (think Bozo the clown) at the same time. They are also short, never blow over your shoulder in the wind, and once you put it on you never have to think about it again. Altogether, if you don't mind the look, a nearly perfect article of clothing. Sure, learning how to tie a bow tie takes a little effort, but after a couple of days it's as easy as tying a shoe lace.

Shortly after I started to wear bow ties at work, a study came out suggesting that doctors may spread infection from their neckties. Some physicians took this as an excuse to stop wearing neckties altogether. Many people assumed my switch to bow ties was influenced by that study, but that's not the case. Although I recognize that longer ties may accumulate bacteria, I also realize that my lab coat does the same thing and I don't intend to get rid of that. I'm not really convinced that neckties have much to do with the spread of hospital disease. Failure to observe proper hand washing techniques seems a more likely culprit.

Over the years, wearing bow ties at work has produced unexpected results. Most importantly, patients and their families immediately recognize me from my tie even if they can't remember my name. Recently, I admitted a patient through the emergency room who, when she first saw me, said, ”Where's your bow tie?” In looking through the hospital records, I saw that I had not seen the patient since 2009. Obviously, the bow tie made an impression. I've also noticed that when a patient is admitted to me to the floor, the nurses will often tell the patients that they will recognize Dr. Hébert because he will be the one with the bow tie. Although there are a few other doctors in the hospital that wear ties, I'm the only one who wears a bow tie.

The tie overcomes several important problems in patient care. First of all, patients are able to remember me, and therefore remember who their physician is. It helps them quickly identify me as a physician, which makes life easier for me, and easier for them. Second, it communicates to the patient what I want communicated -- that I consider taking care of them a formal matter, not a causal one, and that I intend to behave professionally towards them at all times. Finally, it may, at least according to one study, prevent disease. Easier identification, better communication, disease prevention. Sounds like an easy call to me.

My habit has been to wear bow ties Monday through Friday, and on the weekends an open collared dress shirt. I did this for years, but on weekends, I regularly ran into patients who would ask me why I'm not wearing my bow tie. Over time, as the challenges mounted, I caved, and these days I often wear them on weekends, too.

I have not polled my fellow physicians to see why 90% of the men refuse to wear ties to work. I think what they would say is that what matters most in medicine is that the patient gets well, not that the doctor dresses well. While I think this is logically true, it misses the point. Patients are people, not widgets. You can make widgets all day, do it well, and never respect one. You can do the same with patients, I suppose, but the outcome is not likely to be as good.

If physicians didn't believe clothing influenced doctor-patient relationships, none of them would wear white coats. The truth is, there are numerous studies in psychology that show individuals in white coats are accorded more trust and respect than people who don't. If white coats command respect, it stands to reason that a necktie would also. And in my experience, that influence is more subtle and positive than a lab coat that screams, I have a degree! I have a degree! Obey!

The reason most physicians don't wear ties anymore is because they find them uncomfortable. Which is not really true. A good silk bow tie and a shirt with a properly sized neck is not uncomfortable at all. It's just a matter of choosing the right clothing. It's also a matter of getting used to it. But even if there is some discomfort in wearing a bow tie, when a doctor refuses to wear one he is saying that he is placing his own comfort above concern for what his patient thinks. (It's not as if anyone thinks doctors don't pay attention to what patients think!)

Showing respect for another person always takes a little effort. When your neighbor comes into your home and finds you lying on the sofa watching the football game, the only way to show respect is to stand up. It takes effort. If you continue to lie on the sofa you are putting your comfort in front of his. You've sent a message, whether you intended to or not.

Some people would say that I'm making a big deal about a minor issue. I don't agree. If schooling teaches anything at all, it teaches that just because an influence is subtle, that doesn't mean it is not important. Subtle changes upend civilizations. If subtlety didn't matter, no one would choose Coke over Pepsi, a Nike shoe over an Adidas, or a BMW over a Ford. No one would choose to move south for warmer weather, and no one would pay more for a house that faces the ocean than one that is a two minute walk away. Subtlety is not only sometimes important, in most cases it is all the difference. You would think that people who try to interpret smudges on x-rays or listen to heart murmurs for a living would understand this point.

Am I saying that all doctors should be required to wear ties? No. I value personal freedom too much to dictate to others like that. My argument is more general. It is that excellence has its roots in many small things. Those who want to pursue excellence have to look for opportunities everywhere. And I don't see any easier area to step up your game than putting on a decent shirt in the morning and then adding a tie. I honestly think if every doctor in our hospital wore a tie (or equivalent dress for women), the hospital and the doctors would make more money.

But at this point, I'm one of a handful of physicians in my entire hospital who bothers to dress up at all, much less wear a tie. In some ways, wearing a bow tie makes me an outlier. It is strange to think that in our society, the guy who wears a bow tie is now the rebel. On the other hand, look at the paintings of the rebels who signed the Declaration of Independence. What were they wearing?

How I Gave Up and Accepted the Pocket Protector

Tue, 24 Apr 2012 11:04:14 -0400

About a month ago, I had an accident at work. I put one of my gel pens in my lab coat pocket without placing the cap on properly. The pen leaked and ruined the coat and the dress shirt underneath.

Pens and I have a very uneasy relationship. Most people don't realize that doctors, especially those who don't do surgery, write for a living. In the hospital, almost everything I do with a patient involves writing. I write daily notes, I write orders, I sign papers, I fill out forms, I complete death certificates. I write more than I do any other single thing, except talk to patients and possibly talk on the telephone. Since I spend so much time writing, my pen is important to me.

You don't spend 3-4 hours a day using an instrument without developing some very specific preferences. Because I am left handed, I prefer fast-drying ink, the smudge-proof kind. My pens also need to flow very easily, so I can make bold and legible lines in patients' records without wearing my wrist out with bearing down. I am restricted to black or blue-black ink, since most hospitals require it for legal purposes. Sometimes my records will be faxed and photocopied, and occasionally the copies will be copied and the faxes faxed, so clarity is an important matter.

For a long time I preferred retractable pens, but I found that too often I would absentmindedly replace the pens in my breast pocket without retracting them. I have a row of lab coats in my bedroom closet with little black dots on the bottom of the front pocket that prove I am indeed absentminded. To address this problem, I switched to capped pens. My initial resistance to capped pens was that my pens come in and out of my pocket thirty times or more over the course of a day, and capping and recapping a pen would be too difficult. The flip side is that I have to think about the cap every time I replace the pen in the pocket, which takes me out of my absentminded state and forces me to mind the pens. This is the classic psychological trick of making something slightly harder so it commands the attention necessary to get the job done properly. A little like putting the alarm clock across the room so you have to get out of bed to turn it off.

The cap gambit worked. For a long time, I was replacing the cap each time the pen went into the pocket. Until last month, when I forgot.

That put me back to square one. Retractable pens didn't work. Capped pens didn't work. That left the dreaded pocket protector.

Pocket protectors, as it turns out, are almost impossible to find. In fact, the only place I was able to find them was on-line at Amazon. Unfortunately, pocket protectors have such a strong association with computer geeks and clueless science majors that even computer geeks and science majors don't want them any longer. But they work. They are a simple, though inelegant solution to my problem of staining shirts and lab coats with ink. I'm not exactly thrilled with the idea of purchasing them, but in the last accident I lost a $40 lab coat and an $80 shirt. That is a ridiculous cost for the benefit of using my favorite $2 pen. Hopefully they won't look too bad. I have the option, since the lab coats have a side pocket, of stashing the pocket protector on the side and keeping the pens there instead of in my breast pocket where the pocket protector will be seen.

Incidentally, when you put a pocket protector in your cart on the Amazon website, do you know what Amazon suggests you also consider buying, based on what other people bought with their pocket protectors? A pair of Buddy Holly style eyeglass frames, a hat with a propeller on top, a "Nerd Herd" novelty ID tag, rainbow suspenders, and clip on bow ties.

Somebody needs to tell Amazon I already wear bow ties. And frown on the clip-on kind. I have standards, dammit.

The Book Catechism: Field Notes from a Catastrophe by Elizabeth Kolbert

Mon, 2 Jan 2012 22:01:43 -0500

So you read a book about global warming. What are you, a liberal?

Actually, I'm a scientist. And like a scientist, I draw conclusions by collecting the available data and figuring out what it means. Data have nothing to do with politics, no matter what the politoidiots say.

So I guess you are going to tell us you are convinced.

Quite. What struck me about this book was how uncontroversial global warming is. There is no one who studies climate data who thinks the climate is not warming. This isn't even a question. What scientists are debating is how it is happening, and how fast it is going to happen. Kolbert uses a nice mixture of anecdotal evidence and hard statistics to show that the temperature is warming, and shows that it is happening faster than scientists expected it to. She points out the obvious -- that the sea level is rising, the polar ice cap is melting, and observed temperatures are increasing. And she points out the not so obvious -- that species of birds and butterflies are being found in places that were previously too cold for them, frogs mate earlier than they have only a few decades ago, and a hibernating mosquito has adapted its hibernating pattern in a way only explained by temperature change.

One of the strongest reasons to believe in global warming is indirect effects like animal behavior. These effects were not predicted by climate change models, but have been observed anyway. One test of the truth of a theory is that it explains effects that the creators of the theory would never have anticipated. Climate change theory does this in spades.

Climate change can explain why there has been a .1 change in pH in the oceans. There is no competing theory to explain that.

What is the most surprising thing you learned from this book?

Climate change theory is not new. In fact, the first scientist to predict global warming was the Swedish chemist Svante Arrhenius, who won a Nobel Prize for seminal discoveries in the behavior of electrolytes. In 1895, he argued that a doubling of the CO2 concentration in the atmosphere would increase global temperatures by six degrees. Although Arrhenius left out several complicating factors that make his model simple compared to modern calculations, his prediction is close to what today's scientists predict.

Thus, the argument that global warming is some kind of a plot cooked up in the 60s by a bunch of flower children looking for fame and fortune is historically wrong. Just flat out wrong.

What is the strongest argument Kolbert makes?

Not argument, arguments. What makes this book persuasive is that Kolbert shows that there is evidence for global warming everywhere scientists look. Glacier experts, lepidopterists, evolutionary biologists, oceanographers, and even epidemiologists have found direct and indirect evidence for it. And all this evidence fits together. Anyone who denies global warming has to explain away a who lot of coincidences that are explained by it.

So everyone should read this book?

Yes, unless you don't care that the choices you are making right now could cause billions of people to suffer within the next 100 years.

My Board Certification Is Complete! (So Now I Get To Complain.)

Mon, 12 Dec 2011 12:12:40 -0500

Today I finished the last part of my Internal Medicine recertification. I can't say I was pleased by the process. Although I understand the need for some kind of certification process to guarantee physician competency, I think the American Board of Internal Medicine is going about this in all the wrong way.

To complete the boards recertification, I had to sit for an 8-hour examination (fine), and then do 100 hours of learning modules (not so fine). It's one thing to have to sit for a test every 10 years to prove you know what you are doing. But for the Board, taking an exam wasn't enough. I also had to complete 100 credit hours of personal study modules in addition to the exam. And it is those study modules that I want to complain about.

First of all, it's not as if I just sat for the test. Far from it. I studied for months to prepare for that exam. But studying for, taking, and passing a fairly difficult exam wasn't enough for the Ol' Board. They had to lay some lard on that there butter. So they added a whole additional array of requirements for recertification. Just a bunch of stuff I could knock out in my free time. On top of maintaining a legal medical license. And practicing medicine every day. And fulfilling the 20 hours of medical education I have to complete (and document that I have completed) annually to stay licensed in the state of Mississippi.

The truth is, I learned little or nothing from these modules, and my time would have been much better spent studying areas in medicine directly related to my practice, rather than doing a series of learning modules that really didn't apply to the type of medicine that I do.

My cynical self finds it easy to believe that the Board added all this additional material simply so they could charge me more money for board certification. It's easier to justify charging several thousand dollars for a test when you throw in a whole lot of busywork as lagniappe. And busywork is just what I found it to be. The Board tries to emphasize evidence-based medicine, and yet, there isn't a whit of evidence that 100 hours of board learning modules will improve the medical care my patients get. In fact, I can assure you it won't.

It's too many hoops to jump through. I already have to devote a large amount of my energies as a physician to maintaining compliance with the many, many, many federal rules that are now imposed upon the practice of medicine. I have to deal with insurance issues, documentation issues, and hospital demands in my routine practice. In the last few years I have seen regulations explode in every area of medicine, while the amount of time that I have to comply with them all remains fixed.

(And for you Obamahaters, don't blame this on Obamacare. These regulations have been gradually set in place over many years. They have more to do with insurance companies saving money than with the most recent flavor of health care reform.)

The American Board of Internal Medicine is supposedly composed of physicians. You would think that a group of physicians would look for the least time-consuming method to ensure physician competency, especially knowing as they should all the other bureaucratic problems we face in routine medical care.

Understand that I'm not suggesting that no regulation is needed. Only that the burden of regulation should be kept at a level that is proven to benefit patients, and not at the level the Board of Internal Medicine would like it to be in their dream world. No matter what, the number of rules I have to comply with to keep that diploma on my wall should not rest solely on the judgment of people whose job security depends on more and more regulations rather than fewer and fewer.

The Book Catechism: A Game of Thrones

Mon, 3 Oct 2011 12:10:40 -0400

Why did you read this book?

Not because of the HBO series, which I have never seen. I pay the cable company a king's ransom every month. There's no way I'm paying extra for a movie channel. No, what first pricketh my interest in this medieval fantasy novel was a story in the New Yorker by Laura Miller. She described a runaway bestseller in the fantasy market that had considerable literary merit.

I prefer literary fiction usually. The more hoity-toity, the more I like it. But I'm always on the lookout for the best of the best in other genres when I want a break between Cheever and Borges.

Do you recommend it, overall?

To the average male reader, yes. It's very far from chick lit, but Laura Miller likes the series, so I wouldn't say women won't like it. Just that it's not typical women's fare. This is a hardboiled, gritty, murderous war story. A realistic Lord of the Rings. The story takes place in an alternative universe that -- what are the odds -- resembles medieval England. Some people have called it LOTR for adults, but that is unfair to Tolkien. LOTR is and always has been adult material. It's just that Tolkien has been mined by so many children's authors for ideas that it is hard to approach LOTR without brining the baggage of decades of fantasy books and films with you.Thrones has the advantage of being able to look back over the last 80 years of fantasy writing and avoid the cliches. Cliche-deficient writing is usually going to be superior.

Thrones is a much more realistic LOTR. In Thrones people die, brutally, painfully. If you think Sauron and the Orcs were cruel you ain't seen nothing yet. In Thrones women are raped, children are tortured and murdered. Like the Arthurian legends that underlie most fantasy fiction, Thrones has something of a love triangle. Except one of the sides of the triangle is incestuous.

It's realistic in the sense that it is bloody and cruel, then?

Yes, but it's more than that. In Thrones one character dies from a wound infection. That happens all the time in real wars, but I've never heard of that in fantasy. More than that, there is, at least in this book (it is only the first of seven), very little magic. Much of the sorcery in this book is explained, though not all of it. The wizards seem more like shamans than real wizards. They helplessly watch people die just like everybody else, and apply salves and prescribe medications that the reader implicitly understands are useless. The only drug that seems to work is the "Milk of the Poppy" -- opium. (Sometimes real medicine is like that, too.) In this sense, Thrones is a little like Genesis rewritten by a Deist. Much of the magic is not magic at all.

But there are a few very significant exceptions. The way Martin will deal with these exceptions is the tension that drives readers from this book to its long chain of sequels.

Is there a medical angle to it, since this is a medical blog?

People get infections in this novel. And there's a dwarf that isn't a dwarf in the traditional fantasy way -- that is, a member of a race of short, super-strong people who like to dig for gold. This is a real dwarf, someone who has short stature and abnormal curvature of the spine. Possibly spina bifida, or severe scoliosis, or some other congenital medical problem that would cause dwarfism. That's what I mean when I say there's not a lot of magic in here. The only dwarf in the book is a dwarf because he has a medical problem.

At any rate, I find it fascinating that people in an alternative universe have wound infections. Is this from alternative universe bacteria? Or are we dealing with the usual staph infection? Why have bacteria in an alternative reality? Could it be that the people in the Thrones world evolved from simpler life forms and the bacteria are a remnant of those simpler forms, just as it is in this world?

What is best about it?

Plotting and character. The book is told from the point of view of almost a dozen main characters. To keep all that clear Martin titles each chapter with the name of the character who will be the point of view in that chapter. This is a wise move. If he hadn't made the point of view so painfully clear, this would be a very confusing story.

As it is, the number of points of view creates an intricate plot. And the characters, to meet the complexity of the plot lines, are complex also. I was often surprised at the reactions and interactions the characters had with one another -- this book is far from a simple good vs. evil formulation. There are heroes, and there are villains, but the two sides interact with one another in very complex ways. Characters are punished for being foolish, or haughty, or weak. An alcoholic king suffers mightily for his love of drink, his successor suffers for his brashness. A recurring theme seems to be good people who are punished for not being pragmatic. In Thrones, you suffer for having scruples.

It's hard not to like a book that is so serious about consequences, and looks so deeply into personal weakness.

What is worst about it?

There are no underlying themes. As a highbrow reader I am used to books that comment on the human condition, to use a stilted and overused phrase. Thrones is not like that. It looks at human foibles the way a soap opera does. It shrugs and says, Well, what can you do? The complexity is there to generate interest, not for philosophy. I expect for most readers that is not a problem. It's not really a problem for me, but it isn't what I prefer. I like profound. Sorry.

Anything else you don't like?

This book has a long windup. Like 500 pages long. The prologue starts with what seems like a supernatural event, and then the focus shifts to a medieval swords and knights story. The next supernatural event occurs 500 pages later. It took so long to get back to the theme in the prologue that I started to wonder if Martin had forgotten about it.

There is a parallel story that takes place in a land across the ocean from the main story. Even at the very last page it is not clear how this parallel story will intersect with the main yarn. This puts me off a bit.

On the other hand, it isn't as if the 500 page wait is boring. There are wars, marriages, murders, and intrigue. There's plenty to do and the story moves very quickly. Since even main characters are sometimes killed off, there is a sense of jeopardy not present in stories where death of the hero seems unthinkable.

Short chapters make it easy to digest the complex plot arcs.

Would this book make you read more fantasy novels?

Probably not. One of the things I glean from this book is that fantasy fans like a different book structure than I like. This book is very much like a soap opera. It is composed of many short chapters. The action moves rapidly from one character to another and leaves suspenseful situations up in the air for dozens of pages at a time. The story has a huge, long, slow arc, but there are many smaller arcs that appear and resolve along the way. Kind of like Luke and Laura.

Fantasy folks seem to prefer a story that goes on and on and has dozens of smaller stories within that emerge and resolve along the way. Think of the six-episode Star Wars series, or LOTR, or the infinite incarnations of Star Trek. The attraction is the open-endedness. We literary people prefer a tightly organized story that comes full circle and resolves in a satisfying way. Think of Pulp Fiction or To Kill a Mockingbird. A truly literary work comes to an end, often so hard that there is no real chance of a sequel. Even those with sequels have to re-invent the basis of the story so it will work again. Fantasy novels plan for sequels. If Thrones had ended in a way that had made a sequel difficult, it wouldn't have half so many fans.

It depends on what you like. Fantasy fans prefer 1001 Arabian Nights (which, come to think of it, is the true grandparent of modern fantasy). Stories go on and on, episodically, and could continue forever. Literary people prefer Hamlet, where practically everyone is dead at the end of the final scene. Hamlet II is an impossibility. I don't condemn the fantasy approach, but it isn't my preference.

In other words, you don't plan on reading any more of the series?

I think I will. I bought the first 4 books on sale for 35 bucks. The book was an effortless read. With short chapters, I could read a couple of chapters a day and make good progress. I don't think knocking out a few more will be hard. Nothing much is resolved at the end of the first book, so if I don't soldier on I won't understand very much about what what already happened. It is well-written and entertaining. Just because I am not a fantasy guy doesn't mean I can't like Thrones. I like Star Trek and LOTR without liking their genres.

And anyway, I have lots of time. It took Martin 5 years to write the last book in the series, A Dance of Dragons, and he says he has 2 more books to go. So I am guessing if I get through the next 5 books in 10 years I should be ready to read the last book when it comes out. I'll be standing in a bookstore at midnight behind a bunch of fantasy fans in suits of armor, waiting for the final release. And I will be having fun.