Tips to Help You Regain Your Sense of Self

When I was 10, my family and I lived in rural Pennsylvania. I had three siblings and we made our own fun. We climbed trees, made friends with spiders, and played with the neighbor’s horse until the fence broke and it almost stepped on my baby brother. We mostly played outside to stay out of trouble, but inside could be equally entertaining. There were inside rules—no running, quiet voices, no bouncy ball—which were sometimes circumvented, but almost universally obeyed.

One day, left to my own devices, 10-year-old me disobeyed one of the more sacrosanct decrees of my household: Thou shalt not climb on the cabinets. My need for fun eclipsed my innate desire to follow the rules and up, up, up I went. A moment basking in the glow of my success was followed by panic. My mom was on the porch and would enter the house momentarily. I jumped. White hot pain exploded in my left foot. It had landed, big toe first, in an open box of Legos. I stifled a scream and fell to the floor. “What on earth is going on?” my mom asked. “I think I stubbed my toe,” I lied.

My parents were confused as to how a stubbed toe could cause so much pain, as were the emergency department physicians who evaluated me when my agony had not subsided several hours later. However, I was now committed to my lie and kept retelling the same story. We were reassured that nothing was wrong. My stubbed big toe would heal up just fine on its own. And heal it did, only an inch shorter and fused at the proximal and distal interphalangeal joints. I am reminded of my trivial childhood decision to lie every time I put on a pair of shoes, one of which will forever either be too big or too small. It makes me wonder if the truth and a plaster cast may have been the better option. I also wonder how, without the benefit of time, wisdom, and retrospection, we can know this in advance.

For me, this is also true when it comes to the decisions we make daily. Some decisions are like a mask we put on. Ten-year-old me wanted her “good girl,” rule-following mask to stay intact more than she wanted to have her toe properly addressed. That same year, we fifth graders were eligible to join the school band. During an informational session, they told us that the flute was one of the more difficult instruments to learn. I heard nothing else; that was all I needed to know. Another layer of my mask at the time was proving that I could excel at all the difficult things. Flute it was, regardless of whether or not another instrument would have brought me more joy. The elements of our masks may be genetic, learned, taught, or arise from trauma or other experiences. They are almost always well intentioned.

However, I believe that the mask analogy isn’t entirely accurate. These things do not make up our masks; they make up our casts. They are put on to protect us or to help us move with more ease through our circumstances. There are plenty of resources available to show us how to add layers to our casts. Facebook and Instagram have taught a generation to post smiling pictures showcasing “Living Your Best Life.” The importance of this careful curation of visual snippets of your life is to project the image of who you want the world to think you are. Peeling away the layers and exposing what’s underneath is not nearly as publicized or glamorous.

Jennifer A. Villwock, MDI was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other. —Jennifer A. Villwock, MD

I recently gave a local TEDx talk. Some of what I said you might have read before in my last wellness column (ENTtoday. 2018;13:1). Some of it was new. The gist of the talk was about the importance of the stories we tell ourselves about our experiences, illustrated by examples from my life as a surgeon. Some people told me my talk moved them to tears. Several that knew me during the difficult stages in my life that I talked about said, “I was really struggling then too. I didn’t have anyone to talk to because everyone seemed to have all their stuff together except me. If only we had known, we could have probably really helped each other.” I didn’t say anything that most of us haven’t experienced. I just peeled back a tiny bit of one of my casts.

So what happens if you don’t take a cast off or if you don’t know how? It gets itchy. Probably a little smelly too. The strength underneath can atrophy, the skin turning pale. As time progresses, it can take not only an increasing amount of effort, but also courage, to try and take off the cast. Because of this, we may elect to accept the itch. I wonder if more of us were willing to peel back our casts with an attitude of, “Hey, look at this. Isn’t this strange, but also normal considering what we’ve been through? Won’t it be cool to watch this limb rehabilitate and be strong again?”—would we all be healthier as a community?

Because the location and substance of our casts can be so different, generic one-size-fits-all wellness advice can fall short. For example, online wellness modules are typically not universally well received. At best, one size fits some. Additionally, this type of well-intentioned advice can be counterproductive. If you absolutely cannot sit still, hearing that you need to do sitting meditation daily may just create stress and angst and another plaster layer on your cast as you try to comply. Similarly, I dislike running; my marathon-running partner is my exercise-kryptonite. The “couples who sweat together, stay together” mantra does not apply to us; trying to follow it would harm our relationship.

Do you know where your casts end and your own skin begins? As you head to bed and reflect on your day, maybe catching a glimpse of yourself in the mirror, do you ever get that nagging sensation that you’re not who you wanted to be? Great news! This is your own subtle call to action and tomorrow is another opportunity to be the better person you had hoped you would be today. The only question now is what to do with that sensation. Perhaps consider answering the following questions for yourself and experiment with implementing the answers in your own life:

  • What foods do you actually enjoy eating that also healthfully fuel your body? Eat those things. If you don’t know, ask for help. Your health insurance may include free health coaching or nutrition perks. Maybe organize a healthy potluck or meal exchange.
  • What activities do you enjoy that move your body and keep you active? Do more of that. If you don’t know, consider signing up for a random class or take advantage of a Groupon offer.
  • Feeling too introverted or embarrassed for an exercise class? Sign up for a two-week free trial of one of the many exercise apps available.
  • Do you have a hobby or interest? Nurture it. Can’t remember what you find fun? Ask a friend or colleague for a recommendation or to come with you to a random community event. (I recommend children’s musical theater. There are few things cuter than a multitude of 5-year olds singing Disney songs!)
  • Do you like to create? Decide to make something and, if you don’t already know how, watch a YouTube video and learn (if you’re interested in crochet, check out Wooly Wonders crochet channel ϑ). If you realize you hate the process halfway through, give yourself permission to quit!
  • What new horizons would you like to explore through music or literature? Ask a friend if they’ve come across any up and coming artists or find an open mic night. Maybe join, or start, a book club.

And to you medical students and residents reading, or anyone else who’s overwhelmed with their exceptionally busy life, actively thinking to yourself, “I do not have the time, or the money, for any of your suggestions,” I see you. I hear you. I understand. Perhaps a follow-up question to the ones above may be, “What is the smallest next step I can take towards those goals?” Could you carry almonds or other nuts in your white coat pocket to have a healthy snack option? Can you commit to taking the stairs up one more flight of stairs than you normally would while rounding on patients? Can you sneak away for five minutes in between consults to go stand in a patch of sunlight and take 10 deep breaths? Could you focus on having one genuine, human interaction with another person per day?

As you consider these options, be kind to yourself as you experiment. Not everything is going to feel “right.” It may take some time to remember who you are under all the layers and after all the years of focusing on your training and the welfare of others. Try to avoid “should-ing all over yourself” and doing things out of guilt because they’re what you think you’re supposed to do, lest they drain you while adding another layer of plaster.

“Love takes off casts* that we fear we cannot live without and know we cannot live within.”—James Baldwin

*original quote: “Love takes off masks…” 


Dr. Villwock is an assistant professor of  otolaryngology–head and neck surgery in the division of rhinology and skull base surgery at the University of Kansas Medical Center in Kansas City. She is also a member of the ENTtoday editorial advisory board.

Call to Action

How you can explore your sense of self:

  • Sign up for a class or take advantage of a Groupon offer.
  • Organize a healthy potluck or meal exchange.
  • Sign up for a trial with one of the many exercise apps available.
  • Ask a friend or colleague to accompany you to a random community event.
  • Decide to make something and, if you don’t already know how, watch a video online.
  • Join—or start—a book club.
  • If you know you don’t like something, allow yourself to say no, and try to let go of feeling guilty.

ENT Today

Clinical Judgment: Balancing Evidence-Based Medicine and Patient Self-Determination

Clinical Scenario: You are seeing a patient, Henry Jones, in your faculty clinic with a second-year otolaryngology resident. Mr. Jones is a 78-year-old gentleman who was referred by a neurology colleague for the evaluation of an incidental finding seen on an MR scan obtained during the course of a late-onset Alzheimer’s disease workup. The neurologist sent both the scan images and the neuro-radiologist’s report, which stated that, in addition to some early changes suggestive of neurodegeneration, there is a 3-mm presumed acoustic tumor in the right internal auditory canal.

The resident evaluated and examined the patient prior to presenting him to you, and you confirm the history, signs, symptoms, and examination findings with your own evaluation. Mr. Jones and his wife explain that he has had some hearing loss that has been present since his discharge from the military, where he completed 21 years as an aircraft mechanic. When pressed, he indicates that perhaps his hearing is worse in the right ear, but not substantially so. The tuning fork tests at 512 Hertz were normal. The neurological examination, including neuro-vestibular, facial, and oculomotor tests, was unremarkable. The patient states that he has had some occasional imbalance, but no falls and no vertigo. His neurology consultation was primarily for memory loss. You feel that he appears to be competent in his judgment. Before the patient is escorted to the audiometry suite, he emphatically states that he is not interested in any surgery or radiation at this time, which is what the neurologist had mentioned to him.

You and the resident return to discuss the findings with the patient, and review the MR scan, the audiogram, the history, and physical findings. An onsite audiogram demonstrates bilateral noise-induced hearing loss with a downward slope from 1000 Hertz, slightly worse in the right ear. When queried about what should be the recommended course of action for the patient, the resident excitedly tells you that, with a small tumor, either surgery or radiation therapy would be indicated. He further shows you printouts of several systematic reviews that support early intervention to lessen the effects of the mass on auditory and vestibular function. You remind him that the patient stated he did not want surgery or radiation treatments, but the resident makes his case for intervention—“We’re here to cure disease, aren’t we? And, we know much better than the patient what treatment is called for.” It is clearly time for a teaching moment.

How would you handle this moment?


Discussion

The current state of patient care has been significantly influenced by the expansion of, and reliance on, evidence—acquired through outcome studies, systematic reviews, higher-level research, and other scientific work. There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care? Past generations of physicians relied heavily on the history, physical examination, fundamental diagnostic tests, and subsequent discussions with patients about the physician’s diagnosis and recommended treatment. While technological advances have greatly enhanced physicians’ diagnostic capabilities, some feel that it may have been at the sacrifice of an extensive physical examination and patient-physician discussions. The profession now has become increasingly reliant upon algorithmic medicine, which outlines, to a significant degree of complexity, protocols and best practices, which are designed to reduce variance in patient care across the population and are based on available evidence acquired through scientific studies. The specialty of otolaryngology-head and neck surgery, along with every specialty through the efforts of groups of experts, reviews the available data for many diseases and disorders and develops practice guidelines which inform the otolaryngologist-head and neck surgeon in her/his clinical decision-making. How the individual otolaryngologist utilizes the recommendations, evidence, and data in the care of an individual patient is called “clinical judgment.”

What then, are the elements of clinical judgment that come to play in our care of patients? There are many synonyms for clinical judgment, and many authors have proposed various elements. This author believes that there are four major elements in clinical judgment that eventually lead to the therapeutic plan for a patient. These are:

  • Knowledge;
  • Critical thinking and interpretation;
  • Patient self-determination; and
  • Shared decision-making.

Impacting each element of clinical judgment is the acquisition of experience.

The first fundamental step is the acquisition of knowledge—the knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more—acquired over the long course of education, training, and practice. This author often tells medical students and residents that the acquisition of knowledge is an ethical responsibility to patients and fundamental to their care. It is driven by an ultimate obligation to patients to know as much as humanly possible about the diseases and disorders across our entire specialty. The patient expects us to know the information, or to seek the information as we develop a recommendation for their care. Knowledge in medicine is always changing; therefore, we must continue to learn new knowledge throughout our professional career—it is not trite to repeat the mantra “life-long learning.”

Every act we perform in the course of evaluating a patient is knowledge acquisition—the history and physical examination is appreciated in the context of our knowledge of normal versus abnormal findings; our appreciation of various facial expressions and body language that can be interpreted in the light of the patient’s response to her/his health concerns; an understanding of side effects and adverse reactions of pharmaco-therapeutics—and we both consciously and unconsciously add these observations to our database of clinical medicine.

There is no doubt of the importance of evidence-based medicine studies in clinical decision-making, but where now is the place for patient self-determination and the art of medical care?

The second important element of clinical judgment is the dyad of critical thinking and interpretation. This dyad is informed by our knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies. The history and physical examination give rise to a differential diagnosis set, and from there we work with pertinent evidence to determine how to proceed with diagnostic testing. One can approach the critical thinking either pragmatically or open-mindedly, casting a narrow diagnostic net or a wide one. We are primarily biological scientists, so we can use the scientific method to follow the trail of evidence to the point of reasonable confidence in our interpretation in the context of population-based studies.

The third element of clinical judgment is decision-making. This is the culmination of acquisition of knowledge about the patient (history, physical examination, diagnostic studies, interpretation of the evidence, and critical thinking leading to a presumptive diagnosis) and the consideration of what recommendation(s) should be made to the patient for her/his consideration. The impact of clinical experience is quite important here, for the experienced otolaryngologist has an internal database of similar compilations of symptoms, signs, findings, and diagnoses that inform her/him what should be recommended to a given patient.

At times, the evidence-based recommendations will fit nicely with our working diagnosis, and the course of recommended action to the patient will be clear-cut. With other patients, some uncertainty in the diagnosis and management may be present—so how to deal with, or manage, uncertainty becomes our challenge. Some uncertainty is part and parcel of even the most refined scientific study, and when dealing with human illness, uncertainty may often play a role—uncertainty in how you should proceed in formulating a therapeutic recommendation, and uncertainty in how the patient will consider and respond to your recommendations. Herein lies the fourth element of clinical judgment—patient self-determination.

© BlurryMe / shutterstock.com

© BlurryMe / shutterstock.com

The primary ethical principle in patient care is often said to be “autonomy,” which is the right of patients to make their own decisions about their health care, in the context of unbiased explanation of the options and their basis by the clinician. In earlier times, where information technology was not prevalent, the physician held sway over the recommendations, for she/he had the information. Now, many patients are so much more prepared to make their own decisions, based on their own information, as well as what their otolaryngologist has explained to them. That doesn’t mean that the otolaryngologist has to compromise her/his professional integrity for a patient’s decision, but rather to accept a patient’s wishes after all information has been given and all professional recommendations have been discussed.

In most clinical encounters, physicians utilize some form of “shared decision-making” with patients that usually results in an acceptable therapeutic plan to both patient and physician. In shared decision-making, the physician explores the patient’s personal and health values, which can have a tremendous influence on what therapeutic plan will be acceptable to the patient. Other important factors may be religious and cultural preferences/influences, or constraints due to social, economic, or financial burdens. The otolaryngologist has an obligation to mitigate any “solvable” constraint, but also an obligation to understand and support the patient’s wishes, as long as they are professionally ethical. Gaining experience in dealing with patients, particularly in complex diseases and difficult therapies, can be helpful in developing a shared plan for the patient’s care.

In this clinical scenario, Mr. Jones is an older gentleman with the likely diagnosis of a progressive neurodegenerative disorder. Indeed, he does have a small tumor in the internal auditory canal, but his symptoms at this time are minimal from this tumor. You should discuss patient autonomy and clinical judgment with the resident, and point out that you could achieve a shared decision with the patient and his wife by accepting his decision to not have an intervention, and by offering to follow him closely for new signs or symptoms that may call for revisiting a potential intervention if indicated in the future. At this time, the patient appears to be competent to make his own healthcare decisions, and to cognitively understand the risks and benefits of observing a small acoustic tumor over time. Take the time to answer the patient’s and his wife’s questions to their satisfaction in the resident’s presence. Through appropriate and experienced clinical judgment, you will have followed an acceptable course of professionalism and ethics, supported the patient’s wishes, and shared an appropriate decision with the patient. You also may have impacted the resident’s understanding of clinical judgment.


Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.

Hospitalists as Test Subjects

  1. Knowledge: The knowledge of anatomy, pathophysiology, metabolic pathways, evidence, pharmaco-therapeutics, surgical techniques and outcomes, and so much more acquired over the course of education, training, and practice.
  2. Critical Thinking and Interpretation: Physician knowledge, both fundamental and that which is pertinent to the individual patient through consideration of the evidence in the literature and how closely the evidence applies.
  3. Decision-Making: The culmination of acquisition of knowledge about the patient and the consideration of what recommendation(s) should be made to the patient for her/his consideration.
  4. Patient Self-Determination: Acceptance of a patient’s wishes after all information has been given and all professional recommendations have been discussed.

ENT Today

Letter from the Editor: Otolaryngology Must Address Diversity, Gender Bias

Cultural conditioning shapes who we think we are at any given point in our lives. Few are those who ever challenge or outgrow the beliefs that have been instilled by family and society during those early years.—Mooji

I have always advised students to avoid the doctors’ lounge, especially those filled with pessimistic physicians who talk about how medicine is not what it used to be or reminisce about how the good old days were so much better. Unfortunately, this attitude is non-productive, is highly contagious, and reinforces old biases and behaviors. I worry about becoming one of those physicians. If I resist change in medicine, is it really different this time or am I just getting old?

While I was fortunate to be involved in our specialty’s leadership at a young age, it was obvious at the time that our leaders did not reflect the reality of my medical school experience in Ann Arbor or residency training in Houston.

In March 2007, at the AAO–HNS annual advocacy conference in Washington, D.C., during Richard Miyamoto’s presidency, I attended a meeting of multiple otolaryngology organization presidents. Everyone was discussing issues within the specialty, most of which were focused on clinical topics, specialty politics, or reimbursement problems. Duane Taylor and Lisa Perry-Gilkes, representing the National Medical Association’s otolaryngology section and the Harry Barnes Society, raised concerns about diversity, health literacy, and cultural competency in our specialty. In the room, these topics seemed out of place and were not further discussed. Yet, their comments clearly resonated with the Academy leadership and quickly led to the development of the Academy’s first diversity policy and the creation of the inaugural Diversity Committee. Around the same time, Sonya Malekzadeh and others led the creation of the Section for Women in Otolaryngology. Both groups were immediately given representation in the Academy’s Board of Directors.

When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem.

These impactful efforts, reflecting the leadership of many people over the years, opened a new era in an important ongoing conversation within our specialty. Unfortunately, the people who would benefit the most from receiving this information are the most likely to ignore relevant communications or close their minds to the benefits of different perspectives, equity, or new ways of doing things. People who are committed to change and moving forward bear the responsibility to learn, teach, and reach out to help others. Together, we need to develop better ways to frame the benefits to bring along those who are not ready. This is how change works, and there is still a lot of work to do.

Life and medicine are continuously changing at a seemingly accelerating pace. When we attempt to avoid change and cling to the ‘way things were,’ we stop moving forward and growing, and we become part of the problem. We need to open our minds, try to understand
perspectives that are unfamiliar or uncomfortable, and embrace change. Change will never end. We will never get “there.” We are fortunate to have many exceptionally talented and inspiring colleagues who can help us along this journey. They encourage us to improve and help us provide more effective care to our patients.

This issue of ENTtoday highlights ongoing critical issues related to diversity/inclusion, gender bias, and health literacy within otolaryngology–head and neck surgery. The articles include interviews with many leaders in our field who are actively addressing these issues. Erin O’Brien’s viewpoint on the gender gap in otolaryngology provides a timely update. She makes the point, which can be generalized to many problems facing the specialty, that leaders need to participate in order to address these issues, and affected groups cannot be expected to achieve parity without the support and effort of those with the power to make changes. Duane Taylor, now the current president-elect of the AAO–HNS, discusses the importance of the well-informed patient and the Academy’s new tools to help physicians and patients.

As a specialty, let’s not get stuck in the doctor’s lounge; as leaders in medicine, we should stay open minded, be active and honest participants in these conversations, embrace change, and drive our specialty forward to its ultimate potential.

Ronald B. Kuppersmith, MD, MBA
Deputy Editor, ENTtoday

ENT Today

Letter from the Editor: Medicine’s March Madness

As part of our mission to focus on physician wellness, we thought it would be fun to have an issue focused on a theme many of us use as a vehicle for work-life balance: sports! Finding stories and sources around this subject was not difficult. When we came up with the idea to write a story on otolaryngologists who served as team physicians for professional sports teams, we had more than 10 surgeons to speak to. We have otolaryngologists who have been professional athletes, Olympic athletes, and major boosters of athletic teams, and we even have one otolaryngologist who has had the experience of hiring and firing a Division I football coach and athletic director. College athletics is a passion for many otolaryngologists (just ask any Ohio State alumnus), and March Madness is college basketball’s three-week long tournament that consumes the work force and has even the non-sports aficionado searching the internet for tips on how to best fill out their office pool bracket.

So what is the otolaryngology version of March Madness? That would have to be the Otolaryngology Residency Match, which also takes place in March of every calendar year. The residency match is similar to March Madness in many ways. The college basketball season is five months long and comes down to three weeks to crown the champion. Months of residency interviews, letter writing, and phone calls come down to one day to find out who we will spend the next five years training.

Teams such as the University of Virginia, a No. 1 seed in 2018 that many expected to win the National Championship, lost in the first round to tiny UMBC, learning the hard way that you can never take anyone for granted. Otolaryngology as a specialty learned a similar lesson. For as long as I can remember, otolaryngology has been one of the most competitive residencies to match into. As a specialty, we enjoyed having the best and brightest apply to our programs. In fact, the match got so competitive that otolaryngology soon began to get a reputation amongst medical students and deans of medical schools. Students who didn’t have top Step 1 scores and grades were dissuaded from applying. We subjected the students to special interviews and made them submit written paragraphs in order to select the most competitive applicants. There was an air of superiority that filled many of our programs, as we rested on our laurels and stopped looking for talented medical students, assuming they would come to us. Because of this, the applicant pool, albeit as talented as ever, shrunk in size, and for two years, we were left with more residency spots than applicants.

In sports as well as in medicine, learning from our failures is a hallmark of resilience. In 2019, the University of Virginia again entered the tournament as a No. 1 seed. This time they came prepared and have since won their first two games of the tournament. Otolaryngology learned a lesson from the 2018 match, as we quickly began to acknowledge our missteps and look for ways to improve our match results. We began to understand that there are many more things other than a high Step 1 score that go into making a wonderful otolaryngology resident. Departments made tremendous efforts to reinvigorate their student interest groups and began new programs to expose pre-clinical students to the field. We began to show our appreciation to the applicants during interviews. Instead of the usual box lunch, programs were treating applicants to five-course steak dinners and guided tours of their campuses and cities. Much like the UVA basketball team, our efforts have been rewarded, as we have seen an explosion in the number of applicants. We have again become one of the most competitive specialties, and the residency match of 2019 was an extremely successful one for the field.

Much like the winner of this year’s tournament, we should take the time to celebrate our achievements but know that we can’t rest on our laurels. To continue this success, we must continue to work hard to find and attract students who are talented, diverse, and hungry for success.

Thanks for reading, and I look forward to connecting next month.

—Alex

ENT Today