Who's In Charge Around Here?

I am...I think??

Recently, I received a work-related email. (Riveting way to start a Christmastime post I know but stay with me!)

It was from a non-physician staff member who helps execute the orders I place. The beginning of his email contained normal information that required my attention. It ended, however, with this:

“Just double checking a couple of things…I noticed that you ordered 25 treatments. We rarely use that number here at Man’s Greatest Hospital. It’s usually 15 or 16 treatments.

Also, I see you ordered bolus. Unless there is a concern about skin involvement, we don’t often use bolus in cases like this.”

I had to re-read it twice to convince myself that it actually said what I thought it said. I understood his suggestions. Recent papers had come out that it was probably safe to deliver the same amount of radiation in fewer treatments. My colleagues had started to use this approach in select cases, but in no way would I consider it standard. The data was new and follow up short. I had ordered an appropriate number of treatments for a very routine case.

Assuming the best of intentions, I searched for the question in his remarks. Had I missed something? I switched over to a different program and checked my orders. Perhaps they weren’t clear.

By my third reading, I realized he hadn’t asked for clarification. Or help understanding my thoughts. Or presented any firm data for the changes he proposed. Without meeting the patient (or seemingly even reading my consult note), he wanted (demanded?) me to change my treatment plan to fit his vision of what treatment “should” look like.

I sighed, walked around the physician workroom, and wrote back.

Please follow my orders as written. And in the future, before sharing your thoughts on how a patient should be treated, at least review the patient’s chart.

Just kidding. I wrote those sentences, deleted them and took a breath.

Despite his challenging tone, I knew my response as a woman and as a physician could not match his.

This was not the first time in my career that I had received communication like this. Usually from someone with “less power” than me. And usually from someone (female or male) who hasn’t done basic fact finding before reaching out to me with this “just asking questions” vibe.

A soft declaration. An oblique challenge. A tricky situation.

He did not ask his colleagues or his boss. Instead, he decided to go straight to the source. And he brought with him an unhelpful framework of “we” versus “you.” It’s not slut-shaming per se, but the lack of curiosity and corrective tone conveyed the same tsk-tsk finger-wagging meant to put me in my place.

He also (incorrectly) assumed that I didn’t know the rationale behind the information he presented. Maybe he hoped to mansplain me into changing my mind? Had this approach “worked” for him before, I wondered.

My second attempt at a response began with a long justification of why I had chosen the treatment regimen that I ordered. Dear Reader, I took up my sword and charged at the windmill he set up before me.

In brilliant prose, I wrote two long paragraphs explaining my interpretation of the recent studies that looked at whether shortened treatments were safe in this exact situation. (One had short follow up and another showed double the number of complications in patients who had the shorter course.) I copied and pasted the patient’s pathology report into the email and took a screenshot of the imaging results that indicated skin involvement. I explained that was why I had ordered the bolus. I wrote way more in my response to him than I wrote in the patient’s chart.

But not once, did I consider writing “because I’m the doctor” or “because that’s the way I’ve always done it” or “because that’s the way we did it when I worked at Man’s Other Greatest Hospital.” I’ve treated cases like this for years. This was not complicated so maybe I could help him understand.

Also, I know that the three worst reasons for choosing a medical treatment are:

1. That’s what everybody else is doing

2. That’s the way we do it here at Man’s Greatest Hospital

3. That’s the way I’ve always done it.

I’ve never ascribed to these responses and can’t think of a single physician whom I respect that does. Sure, I’ll fill out dumb paperwork because that’s what the insurance company wants. Or I’ll follow a byzantine pathway even though I find it silly because that’s the way things get done.

But I’ve got a hard stop at making treatment decisions based on what’s trendy. Or what everyone else is doing. Or because you say so. That’s not how I practice medicine.

Maybe it’s because over the past twenty years, I’ve watched trends come and go. For example, in radiation oncology, speeding up treatment (same total amount of radiation just in fewer treatments) is fine…to a point. After that, however, patients can have long term complications that impact their quality of life forever. The convenience of a week or two less of treatment is never better and can come at a cost of a lifetime of annoying side effects. These complications are admittedly rare, but they do happen to real people. I’ve seen it. I’ve taken care of them. And I can’t predict who those people will be.

It’s not that I’m against shorter treatment courses.

Does every patient want to spend less time with me? Obviously!

Do I want you to spend less time with me? YES!

Will having less treatments save you money? Of course!

But (takes a long drag on a cigarette and clinks the ice cubes in my glass of whiskey), I’ve seen some shit. And it takes really great data with looooong follow up for me to put a patient at risk to be the one who has the complication that could have been avoided with just five more trips to the cancer center. I’ve got a high bar that convenience must clear for me to change my ways. And I’m open about my approach when I talk to patients.

Perhaps it’s one of the benefits of age and experience. As my husband often says about construction, “I’ve got socks that have seen more cancer” than some bright-eyed whippersnappers. I’m not willing to take the chances that some of my younger and (blessedly) more adventurous colleagues are. I’m thankful and I support them, but it’s not for me.

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Despite my confidence that I was doing the right thing for the patient, composing a response to this staff member took an extraordinary long time. Why? Because I am a female doctor, and I have to think about these things. For example:

• How do I communicate openness to questions while setting boundaries?

• Reply to his confrontational style without seeming mean?

• Correct his obvious lack of knowledge about this case without coming off as heavy-handed?

Finding this balance feels like walking on a tightrope:

Err too far into openness and people feel that their opinion and mine are equal. This can lead to insistence on implementing their plans rather than mine or long conversations about even the most routine decisions that I make.

Err too far into aloof expertise and risk coming across as “unapproachable” or the absolute worst label for a lady doc: “difficult.”

Learning to define who is in charge of me has helped me navigate these perilous situations. (Yes, even physicians have bosses.) My mentor, Dr. Blackstock, forced me to acknowledge that not everyone’s input on my patient treatment decisions was helpful or necessary.

My work is reviewed regularly by my peers, and I know how to reach out for help when facing a difficult case. I have literal subject matter experts in my phone and a computer filled with the latest in research. I trust my experience, training and knowledge. I can filter through the opinions of others, keep what I needed and discard what I don’t. I also don’t have the time or responsibility to teach everyone critical thinking, kindness or their own limitations.

I applied this framework to the email response that I finally sent. I hope it was received with the respectful acknowledgement yet firm confidence with which it was intended:

My order is correct. Thanks for the heads up about the trends you are seeing.

I stay abreast (haha!) of the literature and employ bolus/less treatment when I feel it is appropriate.

My portion of the treatment planning process is complete and ready for you.

Have a great weekend!

Merry Christmas, y’all.

On my mind…

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Traveling for the Holidays? It’s a great time to binge my podcast, Less Radical!

Episode 1: Who is Bernie Fisher?

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