How One Colleague Made Me a Better Doctor.

In 1991, for the first rotation of my last year in medical school, I took a sub-internship in Cardiology at the Palo Alto VA. The pathology there was legion and a beacon for young doctors seeking diagnostic depth in the diversity of disarray that were the ill veterans. I had been there for my internal medicine clerkship, and I had seen and learned plenty. I was not going back just for the patients, but for a cardiologist I encountered there named Eddie Atwood. Although he had not been the attending on my medicine service, I had watched him facilitate morning report for a week during my medicine clerkship, and I had seen him interact with residents and patients on and off while I was there. Like all the faculty, he was bright, well-read, up to date, and credentialed beyond sufficiency. But that’s not what made him unique. He introduced me to one of my favorite (still) sayings about clinical work and any other type of critical thinking:

“The only thing worse than no data is bad data. The trick, of course, is how to detect bad data.”

He was unassuming enough to be accessible, quick and bright enough to provide assurance, and self-aware enough to deconstruct the pedestals built around him by academic hierarchy. He was humorous in a quiet way, as if he were winking at the whole clinical establishment, urging us to think about what was core and elemental about being a good doctor. He insisted we call him Eddie, so we did. He liked to ask questions. I saw him angry only once, and that was when a resident breezily tried to pass off poor thinking and effort on others without acknowledging his own impact on the patient at hand. And even then, Eddie Atwood was respectful.

So I spent the sub-intern month soaking up pearls like a sponge, little physical exam points not often taught, critical thinking distinctions in diagnosis and cardiology therapy I knew I wouldn’t be getting elsewhere. He had a fellow with him, too, an interventional cardiologist-to-be who seemed to have selected an elective rotation with Eddie for similar reasons to mine. Noah Omoigui was from Nigeria, and he pronounced Eddie’s name -- “Eddie ATT-Wooood”-- in a fluid cadence I enjoyed imitating. I learned a lot from him as well. One day Eddie stopped me in the hall: “Hey, every month I try to spend a little time with each student to give them some thoughts on medicine and being a doctor. You have a few minutes toward the end of the day?” “Sure. What’d I do?” I would later learn to not outguess these conversational ventures, but at that age, and in that context, I just knew some sort of defining verdict, probably quantified and headed toward my evaluation and later my Dean’s letter, to be shown to all residencies and preserved in an infinite time capsule of medical student iniquities, was surely coming. Even from Eddie. “You students are all the same.” He smiled, his hand on the shoulder of my white coat. “Not everything is a score or a pass/fail, you know. There’s more to being a doctor than what shows up in your scores.” He gave me a pat on the back as he headed down the hall. “Sometimes there’s just a conversation. I have nothing bad to say to or about you.” Two hours later found me in the late afternoon slant light, oddly, of an academic classroom wedged between wards.

The Palo Alto VA was less than two years removed from the formidable Loma Prieta earthquake that had shut down the World Series and the Bay Area in 1989, so things were still a bit makeshift. There I was, sitting in a desk like the ones I sat in during high school, with the open side and the place for my elbow. Apparently the room was used for patient education, given the posters about diabetic education, how to keep your hypertension under control, and how to recover your life after a stroke. Eddie smiled at me. I tried not to be guessing. “Did I do something?” “Yes, but nothing bad.” He was smiling and shaking his head now. “You all have so much talent, so much ahead of you, and I have the hardest time getting you guys into a conversation without you worrying about what you’ve done, what mortal transgression you’ve committed.” “Sorry.” He held up his hand, still smiling. “Just let me get started here—we’re about to start running in circles.” “Ok.” “So, every month, I have the honor of working with a new group of young physicians. Some are students, like you, some are residents, and occasionally I get a fellow, like Noah. And I try to watch you, learn from you, appreciate you, as we work together learning how to take care of patients, to help people who are sick get better. I love it. And I teach—it’s my job—but I also learn a lot from all of you.” He paused. This was a different conversation. He kept pausing. I wanted to say, “And…?” but I didn’t. It felt good to have the sun streaming into the room. “So, having done this for a few years, I learn more and more about myself as a doctor, and a few years back, it occurred to me that if I was getting smarter because of what I was learning from experience, from patients, from nurses, from students, from other doctors, shouldn’t I help that process in others wherever I could?” “And…?” I said it. “And…I see things, so I try to tell you what I see, so you can use it.” He scooted his desk out of a sunbeam and squared it so it was facing mine. “You,” he said, “have some unusual traits. Gifts really. But they can get you into trouble.” I knew it! He had seen my darkness and exposure was upon me. “Sounds like a problem.” He smiled and shook his head. “More like a paradox. The things that make us good and unique are also the path to our ruin. Shakespeare was an expert in this, I hear, but I’m just a VA doctor. I’m just trying to help you.” “So what do you want me to understand?” “Well, first of all, know that I do this with every student and resident, so don’t feel singled out. For three weeks now I’ve watched you interact with patients, nurses, your clinical colleagues, and I have to say I am impressed.” My eyebrows went up. “No, I’m not kidding. We all have our gifts, and while there are a few students whose gifts I think are best suited elsewhere, most of you are really blessed with good minds and solid constitutions. So here’s your thing…”

He went on to tell me, to my embarrassment, that my particular strength was the ability to string together apparently unrelated data and clues--garnered from labs, conversations, articles, history, prior workups--arrange them into patterns, and then explain them effectively to people. I felt a bit self-conscious. “So here’s the thing. When you are right, you are going to save lives, and figure out the patient's problem. And when that happens, it’s always going to be a beautiful thing.” There was the pause again.  “There are two problems with this little strength of yours.” “What’s that?” “Well, problem number one is that when you’re right, some people are going to be lost because of the pace you keep, and others are going to be irritated. Neither is a good thing, because we’re always trying to create understanding, not separation.” “Ok. I get it.” (I was feeling less uncomfortable than when this all started) “Problem number two?” “Problem number two is that when you’re wrong, you’re going to be dangerous.You’re going to be dangerous because when you’re wrong, you still look dazzling, people will still be blinded by the luminous confidence of your error, and those who might doubt you, the irritated ones, will have an investment in seeing you fall.” (Oh, if I knew then what I would find out later!) “Sounds like I’m a jerk.” “No, no.” He held up his hand, the faint smile fleeting again. “More that you have to learn how to handle yourself. How to move fast and help people understand and support where you’re going when you happen to see the light early and when it counts, and how to not outsmart yourself when no one else will keep you in check.” “How do I do that?” “Well, I’m not a speed merchant like you from a cognitive perspective, so I’m not sure.” I rolled my eyes. He laughed. “But here are two suggestions. One, make yourself open to feedback, questions, doubts. Not just in your own mind, but in your manner. Let everyone know you are interested in helping the patient, or your team, or whatever, and that that commitment means you’re open to questions, doubts, and comments about how you might be wrong.” “Sounds fun.” “You’ll get used to it. Humility is a good thing in doctors. Keeps us from thinking we’re God, which is a cliché rut for us. If you open these floodgates, you’re going to get a lot of erroneous feedback, but it’s more important to get it than have it lurking out there. If it’s lurking, it’s bad data that’s driving perception, and you know how I feel about bad data. If it’s out there, you can sort it out.” “The second suggestion is this. Always think, when you feel right, how you might be wrong. Say it out loud and ask other people to join you in this search for hidden wrongness. It will make everybody sharper. It will keep arrogance at bay. It will prevent mistakes, some of which you will make if you don’t create this check on your natural speed and perceived brilliance.” “This sounds like a dangerous thing.” “It is. We’re all dangerous. It’s our awareness of our ability to create peril, and how we intervene to pre-empt it that makes us better.”

The sun slipped below the ridge of the Coast Range, and the sunbeam left the classroom. We sat there for a minute, a couple of tired clinicians in the evening of a long day, without saying anything. “Thank you.” I stood up and shook his outstretched hand. “I appreciate it. I will remember your words.” He nodded and seemed almost grateful. I had a brief thought about what he might have been like as a young doctor. “Did anyone ever talk this way with you?” “Now they do. But at your age, at your stage? No one.” And the funny thing is, I did remember his words, especially right after I forgot them and raced into a near mess.
I went back ten years later and thanked him again, but that was fractional compared to the number of times I have paused at a patient door asking myself, “How can I be wrong?” We are taught, as physicians, to think every thing coming our way needs to be rechecked (sometimes a good idea, sometimes a waste of time and trust), but he was the one who taught me to turn that clinical skepticism inward. As I got more confident, I turned it outward again, asking nurses and colleagues and others, “How can we be wrong here? How do we find out?” Some initially thought this small, cognitive re-loop was a waste of time, and even a self-centered chance to fish for observations about how right I was or we were, but eventually they came to see it as a way to deepen our thinking, assure ourselves and the patients, check our work. I even developed a theorem: “The higher the odds that we’re right, the greater the chance we’ll miss something if it happens to be there.” I had had coaches before. I had had clinical teachers and sports coaches. They told me about the game, how it was supposed to be played, what was good clinical thinking and what was bad. But until Eddie, no one ventured onto the game field where I had the greatest chance to evolve or malform—my own self awareness as a clinician and as an influencer of others. I saw Noah, the fellow, later that evening on the wards. “Did you have your talk with Eddie?” He was smiling, his teeth laughing against his smooth, dark face. “Yeah.” I must have looked a little self-conscious. “Was it a bad talk?” “No, of course not. Helpful, actually. I’ve just never had anyone…” “You’ve never had anyone be so positive about who you are, but give you insight about yourself that will make you better, all in one?” “Yeah. That’s a good way to put it.” Then it dawned on me. “He talked to you, too?” “Of course. I think he takes the time to talk to everyone who he believes in.” He scribbled something on a chart. “His talking to us is not remedial, and it’s not diagnostic. It’s a gift, an honor.”

I didn’t think of it that way then, but that was my first “coaching conversation.” It would be some time before I would seek them out, longer still until I became comfortable coaching rather than being coached, longer again before I began to teach others to coach and be coached, and even longer to the point that I learned how to help people create coaching/learning capacities in their clinical microsystems. Maybe it would have happened anyway. Maybe. But it started with a conversation from a physician teacher who took the time to help me get better one afternoon in a years-long string of afternoons before anyone else had. Thanks, Eddie.