Chapter 4
TRUST, MENTORING, AND INNOVATION
Scenario
Lindy Isla sat on a barstool, leaning over the granite countertop in the kitchen of her condo. She was already dressed in her favorite blue running gear and shoes. She felt energized just looking forward to her morning run down by the river. Suddenly, the ringing of her cellphone interrupted her plan. She clicked as soon as she saw it was her mom calling via video chat.
“Hey, Mom! It’s good to hear from you. How are you and Dad?”
“We’re good, Honey,” her mom replied. “And you look great.”
“This is so much better, being able to actually see you as well as talk with you! You look great!” Dr. Isla spoke rapidly and enthusiastically, happy to speak to her parents even though it interrupted her prework routine. “I love your new haircut; I see why you decided to change to a new stylist. That’s a really nice look for you. I see Dad has joined us, too! It’s good to see you both.”
“It looks like we interrupted you this morning, so I’m sorry about that.” Mrs. Isla grew serious. “Your father and I thought we should make sure you know what’s been happening with your Nana.”
Lindy sat back, looking and feeling concerned. It was unusual for her parents to phone so early in the morning, even with the 3-hour time difference between the East and West Coasts. They usually tried hard not to interrupt her on workdays. She knew they were very proud of all she had achieved, being the first child in the large African American family to attend college and to get all the way through medical school as well. They were a loving family, and Lindy had always had a very close relationship with her parents, her two younger brothers, and her maternal grandmother, Nana, who had lived with her parents since Grandpa died 3 years earlier. The phone was the family lifeline, and they always spoke on weekends when everyone could relax and take their time. This call was odd, and Lindy had a feeling of foreboding about what was coming next.
“What’s happening with Nana?” she asked. “Tell me everything.”
“Well, we’ve all been worrying about Nana for a while. You know yourself how she’s been getting more forgetful over the past year. I remember you asking us to take her to the doctor and get her fully checked out when you were here at Christmas. Nana is stubborn and always refused to go, but yesterday she suddenly became very confused and didn’t know where she was for a few minutes. We finally ended up taking her to see Dr. Garcia, her primary care doctor, even though she was hesitant at first. Dr. Garcia has a good rapport with Nana, and he was very thorough. He did a physical and asked her a lot of memory questions, some of which she got wrong. He also ordered some lab tests on her. Anyway, after he had seen her, he invited us to join them. He spoke openly with all three of us and told us that he thinks she probably has early dementia. Nana admitted she knew she was getting more forgetful over the past year and was not really surprised. I know you’ve been concerned about her forgetfulness for a while.”
Lindy saw the strain and the worried looks on her parents’ faces. Her mom was almost in tears, and Lindy knew they needed her to be strong and helpful, however upset she felt. This was the role she had played in the family for as long as she could remember; everyone called her the “family’s doctor.” Her large extended family, mostly spread across the East Coast, certainly treated her that way, always contacting her about problems, medical or otherwise, for her advice and help. She understood that they did this out of respect for her achievements, and that at one level the frequent requests for help were a compliment to her, but she did find them wearing on occasions.
Not this time. Lindy had always been very close to her Nana. It was Nana who had instilled in her the sense of confidence to work hard and to succeed beyond her wildest dreams at college, and Nana who had pushed her to go on to medical school. It was Nana who had read to her from an early age and had instilled a love of books and lifelong learning. Nana had been there through the ups and downs of her teen years, always guiding her to focus on her dream of becoming a doctor. She had taught Lindy the importance of hard work, self-respect, and making the most of her many talents. Although Lindy loved everyone in her family, Nana was her rock.
She held the phone up before her so her parents could see her better. “I’m so sorry to hear that, Mom. Give Nana my love. How is she today? How are you and Dad dealing with this news? Is Nana there at the moment? Can I speak to her?” Her rush of questions spilled out, showing her concern.
“She’s still in bed this morning, sweetheart. I looked in on her before calling you because I knew you’d immediately want to speak to her, but she was asleep, so I didn’t disturb her. She was really back to normal last night and seemed fine at dinner. I’m sure she would love to speak to you tonight if you can call after work.” Her mother paused. “It’s just more of a confirmation for us. I think we’ve both been expecting this but have avoided thinking about Mom’s deteriorating memory, even though you made your concerns clear to us. We just cannot avoid this issue anymore and are going to have to think and plan how we may look after her in the future. For many years yet, I hope.”
Lindy nodded. “That’s right, Mom. I’m afraid there likely will have to be some changes in her care over time if she does have early dementia, but she should continue to be okay for the present. Most people deteriorate very slowly. Unfortunately, you can never predict how people are going to progress, how long they will remain independent, or even how independent they will be. Everyone is different. But Nana has always been a real fighter, so she’ll likely take this as yet another challenge, once it’s all explained to her.” She became wistful. “I’m just sorry I’m so far away from you, and from her. After 9 months, I’m just starting to feel settled over here. I love my condo in particular, and even work is going better than it was originally. But this would be so much easier if I hadn’t moved. I was about to send you and Dad some money to buy tickets so you could come out here to visit me again, but maybe we should put that on hold. I’ll see if I can get a couple of days off to come back and see you all soon. I’d still love for you both to see where I live, and I hope someday you can visit and stay with me in my spare room. There’s so much I would like to explore with you here. That may have to wait for now. I guess a lot will depend on Nana.”
“Don’t worry about that, please, Lindy,” her father answered. “I think you made a good decision to move and to make your own life as a doctor. We’re all so proud of you. Come back when you can, although I do hope we can make the trip out your way eventually. I think Nana will be fine left here if we can make arrangements for her while we’re away; your brothers can stay with her. Anyway, we just wanted to make sure you’re kept up to date. Go now and get on to work, and let’s talk tonight, or this weekend if that’s better for you. We will give Nana your love. And we love you. Bye for now.”
“Goodbye Mom, goodbye Dad. I love you both,” Lindy said, ending the conversation. She decided to still go out for a run, although now she only had time for a 3-mile circuit rather than the original 5-mile jog she had planned. Lindy looked around the condo. It had a very clean, simple look that she loved, with modern minimalist furniture, several pieces in white lacquer. The poster from the New Orleans Jazz Festival she had attended hung proudly over her mantle. Those 4 days in a New Orleans hotel, her flights, and her meals had all been paid for by Nana as a gift to Lindy for getting into medical school. A large window overlooked the river and the track she would be running on momentarily. She put her phone, keys, water bottle, and pepper spray canister into her small waist pack and checked to make sure her condo was tidy before leaving.
Lindy enjoyed running because it gave her time to think and plan. She was a thoughtful, organized person, rather compulsive at times, and very aware of protecting herself and making sure no one took advantage of her. She knew that her inherent defensiveness was perhaps excessive at times and gave her a reputation of being hard to get to know, as though she had a wall around herself. But as a black professional female who had seen and been the victim of all sorts of biases and discrimination in her life, she tended to take her time with trusting new people until she felt comfortable with them.
This morning she had two major issues to think about. First of all was Nana, and what her likely dementia would mean for her. She missed Nana greatly at the best of times, and moving across the country from her family had been very difficult, but overall it had been good for her confidence and independence. Now she wondered whether she should go back to the East Coast, not necessarily to Boston, but somewhere closer so that she could see more of Nana and help her in the future. She knew this would be a very difficult decision that she would have to make in the next year or so. In the meantime, she looked forward to speaking with Nana that evening and knew that she would be peppered with questions from her about her health and what might happen in the future. Nana was nothing if not direct and inquisitive, and she had been telling Lindy for years to be more open and trusting with her friends and colleagues, especially now that she was a full-fledged physician.
Although her Nana was of great concern to her, she found that she spent most of her run along the river on this sunny day planning for her monthly mentoring session with Dr. Shaper. This meeting was her immediate priority.
Lindy liked Dr. Shaper and thought she had a good working relationship with him. Certainly, he had been very helpful to her and had particularly supported her early attempts to work in a different way at the clinic and to use technology to do more consulting with other doctors about their endocrine patients. She acknowledged to herself what an improvement he had made in the clinic and how her life had become more professionally rewarding since she had started there. Still, she found it very difficult to have a good relationship with him as his mentee. She had actually gone as far as talking to Nana about this last Christmas and had been advised to open up a bit more herself. She knew she hadn’t done this.
She thought about issues important to her that she felt unable to talk about with him. The first was simply the fact that she had found working at the clinic much harder than she had expected. She’d come to the clinic hoping to make an immediate impact, fresh out of her fellowship, and felt frustrated that she didn’t really seem to have succeeded in this as much as she had hoped, although she knew it was early days yet, and that she was still going through the transition from resident to attending. She didn’t feel she could tell Dr. Shaper this, however, because she saw it as a sign of her own weakness. He was working so hard to improve the clinic and clearly saw her as someone who could help him, but she wanted to move forward much more quickly than he seemed to appreciate, especially in changing how she practiced. She had recently begun to think that she was only at the clinic because of the debt relief program she was in that allowed her to work for 5 more years and pay off her entire student debt of $250,000. That debt hung over her like the sword of Damocles. She thought about it constantly and had had nightmares about it growing larger and smothering her. The system was so unfair, forcing people like her, who were from poor families with few resources, to develop such debt! This financial pressure, made worse by the need to constantly help members of her family, kept her working, but her frustration at being trapped in such a financial situation was the major reason she did what she considered only a fair amount of work, and little more, at the clinic.
She knew Dr. Shaper was equally frustrated with her for setting such strong work boundaries and refusing to do extra work outside of clinic hours, but she thought this was the only way she could maintain control of a situation in which she felt unfairly constrained by financial pressures. She was exploring doing an MBA1 program online as well as researching other jobs after hours, and she was constantly being approached by recruiters. She dreamed of finding a job where she could reduce her clinical work and combine it with more preventive teaching and educational activities in the community, but none of those jobs matched the financial and debt relief package she had at the federal clinic.
Another issue acted as a block in her relationship with Dr. Shaper as well. She’d thought about this a great deal and had decided that it really came down to her lack of trust in him. She didn’t blame him for this, but she had thought and read about mentor-mentee relationships and knew that they could be fraught with difficulty. This concern was why she had told him almost nothing about her personal life and why he, even after several mentoring sessions, still had no real idea about what she did outside the clinic. She certainly wouldn’t tell him about Nana’s situation, despite how upset she was this morning. He had been trying subtly to find out about her over the course of their meetings, asking questions about what she was doing on the weekend or what television shows she liked. He had talked about movies he had seen and places he had visited to find out if she had also been there. He had even talked about his wife and what they did together on one occasion.
She rebuffed all of his attempts. What she had thought a lot about was why she didn’t trust him. She knew she had had similar reactions to other male mentors in the past and had always found females much easier to communicate with. She had no doubt it was partly a gender issue and that, as a woman, she found it easier to connect with other women who had had similar professional experiences. She had read a lot about implicit bias and how it impacted characteristics such as race and gender, which she knew applied to both Dr. Shaper and to herself, but she thought that this was also something she could not possibly discuss with him. What about the difference in their ages? He was much younger than her father, certainly, but at times he came across to her paternalistically, which she found offensive, although she knew it was not deliberate. So, she saw barriers to trust around age, gender, and race. These seemed like too much to overcome, never mind acknowledging them to Dr. Shaper. As a seemingly genuinely nice and caring man, he would probably be highly offended if she brought her concerns out in the open.
As she finished her run and walked the last 100 yards uphill to her condo, she couldn’t see any way through these barriers except to continue on as she had been and remain a closed book to Dr. Shaper. With today’s news about Nana, on top of her own ambivalence about work, she decided she was right to continue to perform adequately at the clinic but would not take on any additional work, especially unpaid work.
After showering and drinking a healthy smoothie that she had made for breakfast, Lindy rapidly scanned the overnight e-mails on her phone for anything urgent. She found mainly notes from political and medical organizations such as the American College of Endocrinology and the National Medical Association, the latter advertising their upcoming national conference, which she hoped to attend. She had two e-mails from recruiters, and neither looked interesting. She wished the recruiters would indicate where the positions were actually based instead of giving meaningless, overly positive descriptions of the environments. Putting her phone away, she left the condo and hopped into her 4-year-old Honda, aiming directly for the nearest Starbucks. The radio played her favorite jazz channel, which reminded her of the clubs in Boston she had frequented while at college. She arrived at the clinic 15 minutes later, carrying her carefully made grande latte, and went to her office.
As usual, Lindy was in before any patients were booked to arrive so that she could review her patient list for the day and respond to any urgent patient requests. She noticed that the inbox for her EMR2 had about 60 messages in it, which was not as bad a start to the day as it could have been but still meant at least 1–2 hours’ solid work that she had to fit in around her patient load. Her first patient was not scheduled until after her mentoring session with Dr. Shaper. She noted another gap in her schedule around lunch for the monthly clinic meeting. She wanted to review her independent development plan (IDP), which she brought up on the computer.
Lindy had been opposed to the whole concept of the IDPs when Dr. Shaper had introduced them. She had been fortunate to have two really helpful mentors previously, one while she was at medical school and another when she was a resident, and neither had been very formal or insisted on documenting her career plans and directions. She had always thought the most important part of mentoring was having someone listen to her and occasionally gently advise her about possible alternative approaches to the one she was considering. Both of her other mentors had been women, however, and Dr. Seview, her residency training director, had also been black. She had felt much more comfortable with them and more prepared to discuss intimate and personal issues. She was still in regular contact with Dr. Seview by e-mail and phone, and she was the only person Lindy felt really understood her and with whom she had discussed her current feelings about her job and Dr. Shaper. She actually had been quite surprised when Dr. Seview backed up Dr. Shaper’s comments about the importance of IDPs, and because of Dr. Seview’s encouragement, she had finally put a draft IDP together.
Lindy started to review her IDP on the screen in front of her, immediately wondering how different it might be were she to find a new job somewhere else. Perhaps she would simply have to make that sort of move anyway if Nana deteriorated significantly. In the meantime, she read through her draft IDP, which Dr Shaper wanted to discuss today.
Identify Personal and Institutional Long-Term Goals
Why did you decide to work at the clinic?
I like the mission of the clinic, looking after a diverse and frequently underserved community, and I want to be able to educate them and eventually become part of their community, perhaps in some leadership role using my medical skills. I am academically very interested in diabetes, and because the clinic population is heavily afflicted by this illness, I would like to do some research to find out more about how to help them, perhaps using a range of virtual-care approaches.
What do you personally hope to accomplish in your career?
Specific Goals in Focus Areas
1. Clinical Care
Year in review: I believe I am providing good-quality individual care and have started to electronically review all diabetic patients in the clinic, acting as an online consultant to all our primary care providers. I communicate with many patients through our EMR and have asked if I could start seeing my patients on video in their homes, but I was refused.
Future focus of activity: I want to use telemedicine with patients at home and set up monitoring systems for their blood sugars and vitals using apps and mobile devices so that I can work more asynchronously and with larger groups of patients. I want to make access better for my patients.
2. Teaching
Year in review: I have continuously run teaching sessions on endocrinology for all other providers at the clinic and have had good evaluations.
Future focus of activity: I would like to take part in the Project Echo grand rounds on diabetes that are soon to be available. This will increase my expertise and also allow me to contribute cases to the group.
3. Research and Creative Activities
Year in review: I have done very little research in the past year, mainly because I have not had enough extra time.
Future focus of activity: I want to evaluate and write up my internal e-consults on diabetes but need time and writing and statistical expertise to do this.
4. Service
Year in review: I have contributed to the clinic advisory committee of which I am a member and have continuously supported the change goals being set by our medical director.
Future focus of activity: I want to be able to take up more of a leadership position and start to use technologies more in the clinic to both improve patient care and increase our morale.
5. Self-Development
Year in review: My e-consult project has been a revelation to me. Not only do I really enjoy doing the consults, which I find very interesting and meaningful even if it means working asynchronously with patients, but I also like the peace and relaxation I can have while I am doing them, such as playing music in the background. I look forward to these sessions almost like a break. I have noticed that I have been able to think better and work out ways of managing the EMR much more efficiently as a result. I believe I have effectively become a super-user of the EMR.
Future focus of activity: I believe that more flexibility in my work would be great. I would like to be able to do 8 hours per week of my clinical asynchronous patient work at home, at times I choose, and move to a 4-day clinic week so I can more easily take long weekends to visit my family or enjoy myself. I think that using more technologies in my practice will be good for my patients, myself, and the clinic, and I would like to experiment with a range of these.
Planned Optimal Distribution of Effort Next Year
Ideally, I would like to spend at most 50% of my time in clinic but with a focus on becoming more efficient, doing more consults by telemedicine and by introducing apps and how they collect data to patients on a routine basis. I would like to increase my e-consults and asynchronous care to 30%, which will give me more time to evaluate these and write up the results. The other 20% of my time I would like to devote to managing introduction of Project Echo to the clinic and to teaching, mentoring, and supporting other physicians, with the goal of having them learn how to tame the EMR and use a variety of technologies with their patients so they, too, can become more efficient and in control of their work.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
