being a doctor

Put away your tickbooks! Post cards from London, part III (final)

I have been thinking this week of Professor Peterec. He was one of the best professors I had at Bucknell University. He taught political geography with a larger than life presence. Almost live theater. His class was stellar and eye opening for 20 year old college kids. One of the things I remember most from that class was him talking derisively about “tick book travel”. Basically, this is traveling to another place with your list of things to see (your “tick book”), hurtling from one sight to another and checking them off as you go. In doing so, you are little changed as your interactions with true local culture are minimized. I have thought a lot about this over the years and tried to fight the impulse to merely check off sights in my tick book. Of course, to some extent, I still have one; on our first trip to London we made sure to see Big Ben, Buckingham Palace, etc. But I have tried to push myself to go beyond this “ticking”. This has been made easier by being raised by a father who tended to befriend everyone we met when we traveled as a family, whether in Athens or Warsaw or wherever. I am not quite at Tony Kales level yet, but my kids do laugh (as I did when I was their age at my dad) at my need “to talk to everyone!”.

As mentioned in Part I, we have stayed in a different part of London this trip. While the East End is definitely “hip” with lots of pockets of restaurants and trendy shops, it is also very diverse both culturally and in terms of class. Our building, Adelaide Wharf, is surrounded by what the British call council estates or public housing. It has been delightful to see the children marching off to school this week (their summer break is only 6 weeks) in their matching uniforms walking by the flat. Adelaide Wharf itself is a really interesting building and won awards for its design; it includes both privately sold and “socially rented” apartments and contains a large internal garden and play area.

I have loved walking the surrounding streets and seeing the murals on the buildings. Very different from West London.

And of course, the other thing that is quite non-tick book about this trip is the working nature of it.

The rest of the week at the conference has gone very well. My poster was presented on Wednesday. It was kind of hilarious to see what happens to posters if they are left behind. Poster graveyard.

That evening, Tasia and I traveled to Soho to meet the son of one of my best friends from residency. He  is getting his PhD in the UK and his girlfriend is attending medical school in London. We had a delightful dinner at Cinnamon Bazaar and particularly enjoyed comparing notes on British vs. UK humor. And also, getting the important question answered of why there are two toilet buttons in the UK.

On Thursday, we had the big unveiling of a report issued by an international dementia care commission that I was privileged to serve on. Two colleagues from the UK and I gave commentary about the impact of the panel to a crowd of about 150 people. You can read the gist of my comments here. The report has been widely picked up internationally including in the US which is very gratifying. To see a group of international experts come together and get something truly relevant done has been a great process. So very “chuffed” about this as they say in the UK.

That night we celebrated with a dinner in the Covent Garden area at Café Murano and also toasted to a new grant that my team will be participating in. We made plans to meet at the conference that is being held in Chicago next year as well as for two of the colleagues to visit Ann Arbor.

Tasia finished up her week at the National Health Service on Friday afternoon. She has had an amazing experience going to many different types of sites. One of her favorite parts of the week has been the home visits; seeing people in their own homes adds an important part of the picture that we clinic doctors often do not see.

We headed off for a last day adventure, starting off to Palm Vaults, a café and coffee place recommended to us by our waitress at El Ganso several nights earlier (whom we had befriended when we told her we were going to ‘steal’ the 1/2 consumed bottle of sparkling water and she termed us “naughty Americans”).

Next stop was the Hackney City Farm where, missing our 2 dogs like crazy, we got in our fix of adorable animals. We never saw the “inquisitive goose” mentioned in the picture below but the description gave us a laugh.

That evening we decided to go to the West End to see a play and chose “An American in Paris“. It was lovely with exhilarating choreography, striking sets and Gershwin music. A perfect ending to a great trip with its themes of living as an American in another city. Goodbye to London for now!

 

kales@umich.eduPut away your tickbooks! Post cards from London, part III (final)
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Postcards from London 2017- Part II

Monday was a working from “home” day for me. I worked all day from the flat while Tasia went off to her National Health Service clinical observations. Two things about that:

  • It surprises me how quickly a place becomes “home” if I am comfortable. I love this flat. I love the street noise that lulls me to sleep with my open window. I love making myself a cup of strong French press coffee in the morning. I love looking at the flowers we bought at the Columbia Market. Lots of work got done including my prepared remarks for a Thursday press conference at the meeting.

Work from home Monday messy casual.

  • Tasia had loads of interesting experiences at NHS on day one, but the one that cracked me up the most was one of the doctors asking her “Are you in a sorority?” (No.) And then “Are American sororities like what you see in the movies?” She said the room fell silent as she gave her answer and everyone turned to her with rapt attention.

Once back, Tasia and I walked to Shoreditch and went to The Grocery, a sort of smallish Whole Foods-type store where we bought the makings for sandwiches and some pre-made soups. Some blush wine on the deck was a perfect ending to the evening.

On Tuesday, I met a colleague and collaborator in Canary Wharf. This is a really new, modern part of London. You really don’t feel like you are in London there. It is all skyscrapers and business-types bustling off to their jobs. He and I played a round of what felt like hide and go seek to find each other as it turned out his saying “meet me at the Canada Square exit of the Jubilee line” was too vague. Turns out there are about 4 exits and we were at different ones. We eventually found each other after 1/2 an hour via a combination of phone calls (though it was really hard to hear each other with all the street noise), texts and pictures of where we were standing.

Waiting on a friend in Canary Wharf.

We walked a short ways over to West India Quay where we had a lovely lunch meeting at Browns in a converted warehouse area, and discussed our collaborations including a paper we are working on and a possible grant.

After our meeting, he suggested that I head over to the Docklands Museum in a way that is adorably British: “there is a brilliant exhibit on things they have found while excavating for the new Crossrail like people’s skulls and bones”. This turned out to be a great suggestion as this free museum was awesome. The exhibit on the excavations for the new trainline was truly “brilliant” with vivid displays of finds from the Roman (coins, bones), Medieval (Black Death burial grounds) and Victorian periods (lotsa china and goblets). Other features of the museum include a sobering exhibit on the British role in the slave trade as well as a lively exhibit on the evolution of the Docklands including a simulation of walking thru the Docks in the 1800’s and the role the Docklands played in WWII. I had a funny conversation with one of the staff who asked me where I was from and hearing Michigan, responded “Is that what they called ‘flyover country’? I heard that in a Jason Aldean song”. LOL.

Loads of skulls and bones as promised.

This cracked me up for some reason.

Back to the flat, where I met Tasia and we headed off to the Old Spitalfields Market area for some shopping where we found a shop called Gandys that we loved.

Then to fabulous bar called Dirty Bones for some cocktails. My Lavender Martini was sublime (topped with a flaming spring of Lavender. C’mon!) and Tasia enjoyed something called “the littlest Hobo” (cute, right?).

I will dream of this drink for years to come.

We headed back towards the flat for dinner at a local wonderful tapas place called El Ganso where we were so close to the other diners that we could have eaten off their plates. At one point, the diners from the restaurant to the left asked us what we were eating so that they might try it another day!

Three random observations from the past two days:

  • On this trip we have been Uber-ing all over as the area we are staying is not so proximal to the Tube. I have been amazed at the diversity of the drivers; in three days, have been driven by people from Somalia, Romania, Poland, and Pakistan to name a few. The driver from Pakistan and I had a long conversation and he told me how ideal Uber is for him to make a living wage (he now owns his own home and is very “house proud” as they say here) and have the flexibility for his family of three small boys and a wife who is training to be a social worker. He noted that there is no discrimination on Uber (as there might be for more traditional British jobs) as the rides are determined by computer algorithm. So, while I know people feel mixed at times about Uber, I thought this was really interesting.

 

  • I love love love British slang and have my ears pricked up at all times for new words. “Brilliant” for anything good is ubiquitous and known from past trips and my collaborators. New faves include: “lazy bint” (slothful be-yotch), “silly slag” (dumb coarse woman) and “drunk punter” (drunk/bad customer).

 

  • As stated, I am in love with the flat, but I am in hate with the lip on the shower. I cannot stop tripping on it and stubbed my toe so hard, it felt like it was broken. I might be a silly slag with regard to this part of the apartment.

It’s me vs. this lip. Every. Damn. Day.

Cheers for now!

Me and Tasia with her ‘littlest hobo’.

kales@umich.eduPostcards from London 2017- Part II
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Postcards from London 2017-Part I

We left for London on Friday night. This trip, it is my older daughter Tasia and I. For me, a week in London at the Alzheimer’s Association International Conference, as well as meeting with London collaborators on dementia research. For Tasia, a pre-med student, the opportunity to shadow doctors at the National Health Service. On our fourth trip to London, we decided to stay in hip East London to experience a different part of the City. The specific area (Shoreditch/Hackney) has been compared to Brooklyn and the Meatpacking district of NYC. So, pretty different than the places we have stayed before in the West End. Also, having “done” the usual sites (Big Ben, Parliament, Buckingham Palace, etc) on prior trips, we wanted experience something a little more local.

The trip started pretty auspiciously. We had time for a quick snack at PF Changs in the airport and got these promising fortunes.

On the flight, we settled in Delta Economy Comfort with that little bit extra of legroom. However, despite sleep masks and good intentions, neither of us seemed able to doze off for more than 15 minutes at a stretch. Arriving in London at 6:25 AM, we guessed that both of us had had a total of 3 hours of intermittent sleep.

We stumbled thru customs and got in touch with Tasia’s friend and University of Michigan housemate Abby. Abby has been traveling all over Europe this summer and arranged to meet us in London for 2 days. We found a “Hotel Hoppa” bus (the name of which in our sleep-deprived state gave us the giggles as we repeated it to ourselves) to take us to Abby’s hotel. The bus must have stopped at five hotels before we got to Abby’s and we amused ourselves by crabbing to each other about everything and everybody on the bus. Once there, calls were made to the management of the flat where we would be staying. We were dismayed to find we couldn’t get in until 2:30 PM. Now the task was to stay awake, upright, and sane until then.

We dragged our suitcases to the East End where the company offices were and ditched them there. We then headed off to the BOXPARK shopping area of Shoreditch (a popup mall made out of shipping containers) and wandered around. While ordinarily I would have been thrilled by such a jaunt, I found myself tired and completely irritable. Tasia recalls saying at one point,  “Look at that dog!” To which I nonsensically but crabbily replied, “Oh great. Here we go.”

Realizing I had “had it”, I retired to a coffee shop to read email while the girls continued on. We stopped for lunch at Dishoom which we had discovered on the last trip. Dishoom is said to be modeled after the old Irani cafes of Bombay, and has delicious Indian food in a vintage comfortable atmosphere. We sunk into a booth and lunched on Samosas, Ruby chicken (think chicken makhani) and Dishoom’s version of calamari. Feeling slightly better, we realized it was time to go get our suitcases and Uber-ed over to our home for the week.

Sadly, the 2:30 time came and went, and we were still standing outside the building. At this point, I could barely stand up. I tried to sit on my suitcase, and somehow fell over, which cracked the girls up. The building manager saw us and after seeing our paperwork, let us into the lobby to wait. There, to Tasia’s chagrin, I laid down on the couch.

My rest was shortlived as I realized that my phone was dead and I couldn’t reach the flat manager. I found a plug behind a desk and briefly charged my phone to call her. A woman with a baby carriage waiting for the elevator suddenly confronted me “Are you charging your phone? You know, that is electricity we all pay for!”. Dumbfounded and beyond grouchy, I somehow calmly but sarcastically stated “Seriously? I am charging for a few minutes to make an urgent call. But thank you SO much for your concern.” She slunk away and the girls dissolved into laughter. In a Seinfeld George Costanza moment, I realized the only thing that would have made that retort more perfect would have been to bestow a pound on her for the electricity I was using for that minute.

Finally, a woman came down and led us into the flat. Totally worth it. I will let a few pictures tell that story.

Loving the chandeliers.

It only took me an hour to figure out how to turn on the stove.

View of Regent’s Canal from the living room window.

The girls went out for Italian while I headed to the local Tesco for the basics including coffee and single cream (there is no “half and half” in the UK, half cream is hard to find, so I get the same effect by using single cream and watering it down in my coffee). I also purchased a new battery for the smoke detector that was constantly chirping, and was thrilled that I was able to change it myself (usually such tasks are reserved for my engineer husband).

Look at me! Fixing something!

After a shower and some Cheerios, I began to feel a little more normal. I sat on the deck overlooking the bustling street and enjoyed the sunset.

After a wonderful sleep, we woke up on Sunday and headed for the Columbia Road Flower Market, a short walk from the flat. Every Sunday, this street is transformed into a garden of flowers and foliage. Walking toward the market you see people carrying everything from bouquets of roses to giant rubber plants. Of course, I had to buy flowers for the flat.

 

Beautiful bouquets. Crazy bangs due to the cool/humid British weather.

After the Flower Market, we headed to the Geffrye Museum whose stated purpose is to depict the home lives of the “middling classes” in London from 1600 onward. Tasia had found it online and said “Mom, you will totally love this”. While we walked to the Geffrye, we noted weekend “markets” selling everything from paella to hand made clothes everywhere we turned. Once at the Geffrye, it did not disappoint (Tasia knows me so well), with time capsule rooms including my favorite mid-century period.

Art Deco room.

Mid-century room.

Outside, the Geffrye’s gardens (also by time period) were also a delight. I had to laugh at the signs on the lily of the valley that noted not to eat them as they were poisonous. My parents have a ton of those outside their condo in Ann Arbor. Duly noted not to eat.

After the Geffrye, the girls and I went to a smart café called Beagle. I observed to the girls that I was the oldest person in the restaurant—by far. They laughed and then Tasia scanned the place and said “Oh no, there is a grandma over there with a young family”. Haha. Great.

I parted ways with the girls who went on to see some sights since Abby had never been to London. I headed for the meeting at the ExCeL conference center. Located East of the City, ExCeL is monstrous, and it felt like I had to walk a mile to get to the registration. Following that, I loaded up my slides in the speaker’s ready room and headed off to where I would give my talk.

A quick stop in the bathroom confirmed my worries that the cool but somehow humid British weather was funking up my bangs even worse, but there was little I could do about that. I found that the meeting room was much bigger than expected, holding several hundred people. I quickly adjusted my expectations, noting that I would be talking to a crowd rather than the handful I expected in the late afternoon on a Sunday.

Once the bangs start to curl up, there is nothing I can do but smile.

Sitting in on the featured talks right before ours. Cavernous room holding hundreds of people.

The talk went fine and people were very interested in our DICE Approach and WeCareAdvisor tool. As I left the room, people continued to ask me questions, which was very gratifying. Presentation #1 down and 2 more to go later this week!

I headed back to the flat, meeting Abby and Tasia. We walked over to Broadway Market, an East London street running from London Fields to the Regent’s Canal in Hackney that is full of shops and restaurants. We chose Bella Ditta, a lively Italian place and had delicious pasta and shared a scrumptious dessert (forget the name but some kind of chocolate cream-puffy thing).

Off to bed to start the rest of the week! More updates to come. Moral of the story so far: when you hit the wall, push through because what is on the other side is pretty great.

kales@umich.eduPostcards from London 2017-Part I
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The Power of “I don’t know”

My team and I recently had the privilege of attending a course on “Lean” management in healthcare. In a nutshell, Lean is the idea of making work processes visible and understandable, digging deep to find the root causes of problems, making incremental changes to the processes, and then evaluating the effect on the results. Note that I didn’t say “jump to a solution”. We admit that WE DON’T KNOW WHY something is happening. Sounds simple, but it is deceptively hard.

Three examples:

Example One: During our Lean training, our course leaders craftily immersed us in a “Lego Emergency Room” simulation for the first two days. My team was “Team 4”. Team 4 had 8 people who were assigned a job (e.g. registration clerk, triage nurse orderly, ER doc, lab tech, etc). Our overall goal was to get 15 lego patients thru an ER process at different sites (tables).

DSC05382s2Our first run was a spectacular failure. Broken Lego patients, a long waiting room line and loss of money. We only got 1 patient through the process intact. The facilitator came to our group and in debriefing asked us what we thought we needed. “More doctors!!” we cried! “It’s obvious that doctors are the rate-limiting step!”.

However, over the next day as we dug deeper into understanding the process, mapping it and looking at root causes, we discovered that counter to our strongly held biases and assumptions, the rate limiting step (bottleneck) was actually…..CLEAN ROOMS! Meaning our ability to efficiently and effectively evaluate and treat patients in our ER was limited not by our single doctor and his/her speed, but in our ability to have a clean room ready to receive a patient.

Long story short, we eventually caught on and fixed it and we began to transform our ER. A real AHA moment and we couldn’t have had it until we put aside our assumptions and admitted we DIDN’T KNOW why our Lego ER was a mess.

 

Example Two: A big part of my job right now is teaching doctors, other healthcare providers and family caregivers to say I DON’T KNOW when it comes to behavioral symptoms of dementia (agitation, anxiety, wandering, inappropriate behaviors, etc). Many of these folks will see a behavior like agitation and prescribe (if they are a doctor) or ask a doctor (if they are not one) to prescribe a medication. That’s where unlearning this assumption (difficult behavior=need for medication) comes into play. Just like in our ER simulation where we thought the answer was more docs and it turned out to be clean rooms, often the “answer” to a behavior like agitation is found not in a medication, but in figuring out the root cause of the behavior: a urinary tract infection, boredom, an overstimulating environment, etc. But before we can figure out the root cause, we have to convince doctors and others that they need to admit that they DON’T KNOW why a behavior is occurring and start brainstorming the possible causes. In many cases, if we assume any behavior is a “medication deficit”, we miss understanding the actual cause and being able to correct it.

i-dont-know

Example Three: This one is personal. Eleven years ago, my son Theo was born. He was born two weeks early (a scheduled C-section, since I had 2 “failed” vaginal births with my girls). To our surprise and terror, Theo “went blue” shortly after delivery, just after we had arrived in our room. He was whisked out of my arms into the Neonatal ICU. There, he spent two weeks where they tried to figure out why he had apneas AND a club foot with zillions of tests including brain scanning. All negative. This one is harder, because despite a lot of effort, unlike in the Lego ER, the team couldn’t find a root cause. So, one doctor (who will forever live in infamy in our memories) told us that Theo probably had some type of neurological syndrome (he wanted to tie together the apneas and club foot) and would likely have developmental problems, but “not to worry” because “there are special schools for those children”. We were of course, devastated. About a week later, our wonderful regular pediatrician appeared at Theo’s bedside. She looked us in the eyes and said “We don’t know why Theo is having apneas. Another possibility is that he needed more time in utero. Instead of 34 weeks, maybe he needed 38 to fully develop. The club foot may be unrelated. But the bottom line is that Theo will tell us what he needs and we will follow his development and go from there”.

The breathing issues resolved within the next month and Theo thrived and developed. As with any child, there have been bumps along the road (he will never be a track star because of his corrected club foot), but the bottom line (eleven years later): Theo just “graduated” from fifth grade with A’s in most of his subjects. He is a little engineer who can take the most complex lego set and build it in an hour. During the past 11 years, at times, it’s been hard for me because the words the neonatologist uttered have been imprinted at the back of my mind. I have had to watch Theo’s lovely mind and personality unfold NOT knowing automatically that all would be ok.

My beautiful boy.

My beautiful boy.

But in the end, isn’t that true for all of our lives? We never really have any full reassurance it will “be ok”. We have to go about our daily existence not fully knowing and dealing with whatever we are dealt.

Despite these experiences, sometimes, it’s still can be really hard to say I DON’T KNOW. Especially for a doctor. I have to stop myself all the time. We are expected to have all the answers. But often it is the best first step. And often, like our amazing pediatrician,  the best gift you can give a patient or family is to say, “I am not sure. Let’s figure this out together.”

 

 

kales@umich.eduThe Power of “I don’t know”
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