Keep it simple

Opening confession: I’m writing this as much for me as I am for you, readers.  I had intentions of writing about resilience today because it’s been a recurring theme for a bit. Instead, you’ll have to read about it next week.

This morning as I was listening to the weekly dharma message from Susan Piver, her focus was on simplicity in our meditation. As I listened to her incredibly simple (and brief) message, I realized that as I go into a week that is always characterized by absolute pandemonium, simplicity is exactly what I need to focus on right now. If I’m 100% honest, simplicity has probably been a sub-theme for the last couple of weeks for me.  I’ve noticed that I have unintentionally been laser-focused on getting some tasks (which may or may not have been procrastinated upon!) finished; many of them are tasks that involved things cluttering my house and my creative space.  It felt really good to get those things done and get the associated “stuff” out of my way.

So, simplicity.  It seems like an oxymoron if you look at my schedule this week, particularly for the next 2-3 days. I’ve got multiple times that I’m supposed to be multiple places. Yes, I know that I haven’t been cloned (yet), which means I’m going to have to make thoughtful choices and then embrace them. Those choices will absolutely be based upon what is most meaningful to me, and if you’re with me this week you may see me making some tardy entries and early exits. I emphasize the issue about things being meaningful “to me” because that also means that I have time blocked into my schedule to run and for some yoga…because those things are meaningful to me (and, quite candidly, no one wants to be around me if they don’t happen).

I can’t fix the fact that I have chosen these things that will make me intensely busy the next few days, but I can choose how to best manage that busyness. I can be present in the moment (another choice), I can turn off for a few minutes every day (even 5 minutes helps, right?), and I can be grateful (this morning while walking Olivia I reminded myself, “You CHOSE this. And how fortunate you are to have been able to do so.”).

Who’s with me?  Let’s be simple together.

“The key to finding a happy balance in modern life is simplicity.”- Tibetan Book of Living and Dying

Shame, patients, and the Internet

“If we can share our story with someone who responds with empathy and understanding, shame can’t survive.”- Brené Brown

Last week over lunch, a colleague and I were discussing some of the on-line physician groups that are out there.  Some are on-line communities within organizations, others are Facebook groups. While we both acknowledged that some of those groups can be incredibly helpful for building a community around shared experiences in the challenges of our work, she astutely noted something troubling to her, and that I realized had been an intangible quality that had troubled me more than once.

It’s the fact that within that “safe” space there seems to be this more-than-casual practice of patient-shaming (Note: It’s the Internet, people. Nothing is “safe” if someone gets a screen shot.). It’s the discussion the obese patient, or the patient whose lifestyle choices we disagree with, or the patient who keeps turning up in our clinic with injuries from self-harming in a way that judges them.

As physicians we’re known to sometimes do this in person, and it seems to be we’re more likely to do it to women (yes, there’s both anecdote and science supporting that claim).  But the internet, particularly these spaces in which we’re with our own people, provides a whole new area of questions around how we talk about our patients.

I’ve heard the argument that it’s like being in the physician’s lounge to talk about patients in this sort of space. I would argue it’s nothing like that, mostly because we don’t have direct personal relationships with most of the individuals in those communities and you don’t know if someone caught a screen shot of something posted that crossed a line. It would be horrifying to post something, realize later it wasn’t a good idea, go back and take it down, and only have it come back to haunt you later because of the dreaded posterity of the internet.

I get that we’re tired, that many of us are struggling with burnout, and that we need some sort of way to process dealing with patients who challenge us.  I’m not saying that I haven’t (under a cone of silence in a true safe space) expressed frustration with a patient and/ or their family; if you haven’t EVER done that, you’re a better person than most of us in healthcare, and we also want to know where you acquired your collection of perfect patients. What I am saying is that we have an obligation as leaders and as human beings to think carefully about the reprecussions of things we say and things we write. More importantly, even when we’re tired and cranky and just DONE, that’s the time we need most to call on our compassion and remember why we chose this profession in the first place. And, of course, we need to choose our audience very carefully when we really just need to vent- and we need to stay out of judgment when we do.

Before you post that patient story in a community or group, think about how you would feel if you knew that you or someone dear to you were being written about in the way you intend to tell the story.  If the answer is either “not very good” or “I’d be furious”, it’s wise to reconsider your decision. And if you see or hear something that makes you uncomfortable, I would encourage you to let the author know that it does and why. We need to learn from one another, and we need to encourage one another to be our very best selves.


Leadership and the ambition gap

The McKinsey 2016 Women in the Workplace report was recently released; it’s taken me a bit of time to process the information in it. It’s complicated, and in the throes of a Presidential campaign that is rife with misogyny, it might even be a bit discouraging. We know in professional America, and in academic surgery, that a significant fall-off occurs in the number of women as leadership roles become more powerful. In academic surgery, we see it with the drop from 16% of Associate Professors to 9% of full Professors; we see it with the paucity of women in leadership roles in major organizations; we see it with the number of women who are department chairs (recognizing this number has improved dramatically even in the last year).

We know that women often simply don’t seek promotion to the highest levels, perhaps because work-life integration is more acutely present for women in our society. Perhaps its because we have an unconscious bias against ourselves that only allows us to take a chance on that “big” job once we’re 100% qualified (or, perhaps, more than 100% qualified).

Or maybe, just maybe, it’s because we’re programmed to think of “power” and “ambition” as dirty concepts.  They’re not ladylike, and therefore we don’t want to be in that top role because that would require us to be ambitious and it would require us to use our power.

Gap in Leadership Ambition

Gap in Leadership Ambition

This week I saw an interesting complement to the idea of the the ambition gap, in which Anne-Marie Slaughter hypothesizes that women perceive ourselves as able to have a greater impact at the center of a “web” than at the top of a hierarchy. While her idea that women don’t understand the impact we can have at the top, it’s also plausible that we are so much more comfortable working collaboratively that the idea of having diffused impact through a network is what makes the most sense to us. What we may be overlooking is that we can use the same high-touch, collaborative skills when we’re in that “big” leader position, and use it to our advantage.

Maybe it’s time for us to change our thinking and stop being one of our obstacles (because heaven knows there are plenty without self-sabotage). Maybe we need to realize that it’s okay to dream big, and that it’s okay to start looking even when we don’t think we’re quite ready.  Maybe, ladies, it’s time to leap- and our nets really will appear.  It’s a win for each of us who is ready to do so, and it’s a bigger win for those coming after us as they see our courage, our commitment, and our strength.



October Reading Round-up

Lots of great stuff out there, so let’s get started.

Interested in surgical culture and patient safety?  This Viewpoint reports the content of a panel during the 2015 Surgical Outcomes Club meeting addressing innovative approaches for modifying surgical culture.

Also in the JAMA Network, an on-line piece from JAMA about fluid responsiveness in hemodynamically unstable patients.  This is a high yield article with an accompanying author interview.  Highly recommended!

How should we think about honors criteria for the surgical clerkship? Here are some ideas (which are the product of a SERF fellowship!)

I’ve been spending quite a bit of time over the last year working on workforce issues as they relate to surgical GME, so this Academic Medicine article piqued my interest as we consider new ways to train.

Shameless self-promotion moment!!! I am so excited to see this in print, and I got to hold a copy in my hands last week.  Y’all, I’m a book editor!  Thank you to everyone who contributed; you made what could have been an onerous project downright fun.

And for your reading pleasure, our September book group assignment was The Underground Girls of Kabul.  It was a simply amazing snapshot of an Afghani subculture.

Happy Fall, y’all!

Today’s installment: My life as a policy wonk

Last weekend was an important weekend in Washington DC, not just because of the opening of the National Museum of African American History and Culture, but because it was the Fall meeting of the American College of Surgeons Health Policy and Advocacy Group (HPAG).  For those who aren’t familiar, the HPAG is the leadership group within the College that works on political issues on our behalf as an organization.  For years, the HPAG was incredibly focused (almost singularly so) on SGR repeal.  Now that we’ve checked that box, the HPAG has been able to move on to a broader variety of issues; some of these are around MACRA, the replacement for SGR, and many of them are not. Today’s blog mission is to let you know what our key HPAG topics were last weekend, and to start to educate my surgeons readers on those issues.

So…in agenda order…my take on our top 3 topics from theFall 2016 HPAG meeting-

GME– A small group has spent the last 9 months (oh, that timing seems appropriate!) developing a white paper on GME that can be used in discussions with members of Congress and their staff. Meaningful GME reform, as we are describing it, includes the components of workforce, finance, accountability, and governance. Within these four areas, the white paper includes the following proposed steps:

  • Workforce- support healthcare workforce data collection and research
  • Finance- maintain current levels of GME financing and appropriate temporary additional funds to support a GME modernization and quality improvement program
  • Accountability- combine DME and IME into a single stream of GME funds
  • Governance- move toward a regionalized GME governance system

While this gives you a crude outline of what the GME workforce group proposed, I hope to share more with you about this in a month or so once it is approved by the ACS Board of Regents. This is an area I’m particularly excited about because of my own roles in surgical education, and because it represents an opportunity for our profession to lead.  Change is coming to GME; this is our chance as surgeons to help define what that change looks like.

Global codes data collection– CMS has proposed onerous data collection around 10-day and 90-day global codes. The current proposal is for ALL practitioners who provide services under these codes to collect data on ALL patients served under these codes and for ALL services other than the procedure. G-codes were developed in conjunction with SAGE that require reporting of care in 10-minute increments, and using vague descriptors of “typical,” “complex,” and “critical.” The one that is most interesting to me as a burn surgeon is that “change dressings” is included as a typical visit.  Anyone who has spent any amount of time in a burn clinic knows that our dressing changes are anything but typical, and really don’t belong in the same category as a dressing change on a patient who had laparoscopic surgery.  Also, this idea of 10-minute time increment reporting strikes me as ludicrous because it is entirely inconsistent with any workflow (and quite frankly, would interfere with providing actual patient care, which is what I believe I’m supposed to be doing). The ACS is asking CMS to alter their plans to only obtain data from a representative sample of physicians and to avoid use of the unvalidated G-codes.  Again, stay tuned…I’m sure there is more to come on this, including an ask for people to reach out to their members of Congress.

MACRA and QPP and APMs and MIPS- oh my! Yes, it’s time to dig in around the alphabet soup that replaced the SGR. The most important thing for you to know are the following two things:

  1. The ACS is working to develop APMs (Alternative Payment Models) for common procedures in conjunction with Brandeis. Again, stay tuned.
  2. The ACS will have a major education campaign for us around QPP (Quality Payment Project). If you want to see the resources that are being made available, please look here. There are four things that you can do to get ready for MIPS (Merit Based Incentive Payment System)- 2016 participation in PQRS, review your quality and resource use report (QRUR) from CMS, review the clinical practice improvement activities list when it’s released in November and choose 6 for 2017, and make sure your EMR is ONC certified/ review your meaningful use data. None of these things are terribly tricky, none are designed to be terribly time-consuming.  User-friendly videos, all of which provide information in digestible bites, will be available soon to help make this process as seamless as it can be for all of us.

I want to be clear- these are not the ONLY things that HPAG and the Advocacy and Policy Division are working on.  They’re simply the three things that struck me as the most pressing, most meaningful areas that the DC office and the ACS physician leaders are addressing.

And now…back to our regularly scheduled, non policy-wonk programming.

Being and belonging

Earlier this week, I got into this Twitter-sation with my friend Arghavan Salles:

Belonging and academia

Belonging and academia

As you can tell, I moved the needle a bit in this discussion, doing so based both on data I have (I’m working on the manuscript, I promise!) and anecdotes from talking to surgeons who are struggling with career advancement.

When I talk to friends who are struggling in their career, be it in academic surgery or another profession, I consistently hear two integrally related ideas from them.  One is that they truly don’t feel like the belong where they are; they aren’t aligned with their company or institution for some reason, be it an issue of core values or goals. And as part of not belonging, I find that many of them try desperately to fit in and often feeling like a round peg in a square hole.  Those attempts at conformity are, if nothing, destructive to both their satisfaction and their achievement.

We see this sense of exclusion, of not fitting in around gender in male-dominated fields like engineering (full disclosure- my best friend is a woman engineer, and she may have more awful gender bias stories than I do, though she has also stuck it out and is incredibly successful). We see it in policing around organizational culture and institutional racism.  Ironically, we could use social accountability, in this instance playing on leader’s interests in fitting in, as a way to improve diversity and inclusion.

As leaders, we have to embrace that it’s not fair of us to try to fit round pegs into square holes; when we’re recruiting, we need to have the courage to tell someone that their interests or ethos may not be a good fit for our organization so that we don’t set them up for failure. As leaders, we also have a responsibility to create a culture that is inclusive and that can accept differences. I understand that resource limitations mean that every department cannot have expertise and resources in every area that might be relevant for a junior faculty member’s career development.  The time to think about that is during recruitment-do we have it or can we build it for them- rather than once the new faculty member shows up only to realize they won’t be able to do what they view as meaningful work.  They’ll be forced to try to fit in, rather than to belong, because they’re always going to have a sense that what they do doesn’t have value where they are.

I want to also be clear that I don’t expect every single academic department to be a cookie cutter of other departments.  That would be boring, and wouldn’t be good for our patients or our profession.  We should institutionally embrace our strengths and capitalize on those and recruit appropriately. If someone wants to be a public health researcher and trauma surgeon, we should support that person going to the best place to fulfill both of those professional goals. If someone wants to be a surgical educator and a vascular surgeon, we should do the same. What matters is that there is a “home” for everyone who wants to be here within the house of academic surgery (yes, we need to redefine what being an academic surgeon means!), and that we find them that place where they can thrive and belong.  It’s time to move past fitting in.  Our profession deserves that, and so do our junior colleagues who have plenty of amazing ideas.

Rule Number 5: Everyone’s an equal fighter

PSA: It’s Women in Medicine month.  I would be completely remiss if I didn’t have at least one feminist post this month.

And a warning: Have you heard of Feminist Fight Club (FFC)? No? I’ll warn you that there’s some salty language over there, so if you’re easily offended it may not be for you. That said, it’s a how to guide for fighting sexism with plenty of data.  It’s my current read, and I’m loving it. It’s also providing me with some inspiration.

Before you question if there’s a need in surgery and in medicine for something like FFC, I assure you that there still is. Although women have been half of all medical students for a decade or more, our gains in academia and leadership simply aren’t matching the numbers there- and it’s not simply a time decay phenomenon.  Women enter academics at a lower rate, and our attrition rates are higher.  Even with our equivalent levels of training, we are paid less. These are all simple facts. So, yes, while FFC isn’t written about careers in medicine, it’s no less applicable in our professional world.

Bennett divides her stories and facts into a few key areas:

  • Know the enemy (for the record, it’s patriarchy, not men in general)
  • Know yourself
  • Booby traps (a/k/a “office hospital politics”)
  • Get your speak on
  • F you, Pay me
  • WWJD- What would Josh (a really average white guy) do?

Interestingly, several of these concepts, particularly those around effective communications,  align with key features of Executive Presence, which were published in a more “formal”/ professional  manner.

One of the bits in Feminist Fight Club that resonated the most with me was one of the ground rules for Bennett’s group- no mean girls. We are all in this together, and if we’re busy fighting with you, we can’t get the work done.  You’re a distraction. If you’re a mean girl, we’re still fighting the patriarchy on your behalf.  We’re just not including you in our meetings about how we’re getting it done. Work this important requires a drama-free zone.

I’m going to borrow Bennett’s questions that she includes as discussion topics for a Feminist Fight Club meeting, and I’m going to encourage you (reader) to think about them, to develop your own set of responses.  Note: Men and Women both welcome to play!

  1. Where do you want to be in 5 years?
  2. What’s your biggest pet peeve at work?
  3. What career goals do you have, and who can help you to achieve them (include yourself on the list!)?
  4. When is the last time you were proud at work? Why?
  5. (For those who read the book) Try out a FFC ninja move, keep notes on how it worked, and report back to some like-minded friends.  Guys, you also have FFC ninja moves that start on Page 239. We’re all in this together.

You’re not crazy.  It is real. And being aware of it is the first step to solving the problem.

Apropos of nothing at all: The best piece of advice appears on page 103- Take the nap. 


Searching for meaning in it all

If you’re not someone who reads The Oatmeal on a routine basis, I’m not going to chastise you right now (though having a baby vs. having a cat is fantastic and you’ve totally missed out).  Instead I’m going to refer you immediately to a recent post on unhappy. (h/t Jessica Blumhagen, excellent surgery intern and human)

Now that you’ve read that, I want you to think about if you are truly, completely joy filled every moment when you are doing the things in your life that mean the most to you.

I’ll start: I’m not.

Do I have those moments of indescribable joy when I’m doing my clinical work, when a learner has an “Ah-Ha!” moment, when I finish a half marathon…you know, those things that I find to have meaning?

Sure, I do.  But it’s not every single minute that I’m there. Some days it’s a vast minority of them.  Recent example: I ran the Bozeman half marathon on Sunday morning after a fairly tough call week.  It showed in my performance, which was still a strong run (just not my best). I had LOTS of not-so-fun, definitely not joy-filled moments during the run, even though the scenery absolutely helped. When I was 100 yards from the finish line and looked over to see my mom and my Olivia-dog? Joy.  And a reminder of my accomplishment, something I am lucky to do.

And during my Sunday run, as we’ve all had in the midst of meaningful activities when we get into a “zone,” I also was in that amazing state of flow. It’s a state that as surgeons we find ourselves in during the middle of one of those great cases, when it’s all just going and you’re completely wrapped up in it and nothing can get into your bubble. It’s something that my running friends will recognize when you realize you’ve just clicked off 3 or 4 miles seemingly effortlessly.

I love the idea that to achieve flow that you need to do things that are challenging to you- it’s not the easy stuff when it happens. Matt Inman’s description of being “perfectly unhappy” aligns nicely with that idea when he talks about running 50 miles, reading hard books, and working long days.  I think that his comic struck a nerve for me because distance running (not 50 miles!), reading literary fiction, and well…y’all know about my job…anyway, I understood what he was saying about doing things that are meaningful to us and the importance of that even when those things are hard.

I’ll give my usual disclaimer: your meaningful isn’t going to be my meaningful. You may not run, and you may not love complicated books, and you may not have found “your” career niche.  That’s okay, and it’s important that we each be a little different from one another.

But I did want to remind us all (and perhaps maybe myself more than anyone right now) that it’s not going to be fun every day and it’s not going to be easy every day.  What it should be every day is a celebration of doing something that is meaningful to you. My new going to bed at night question that I ask myself is, “How did you show up today?” It provides me a compass for meaningful activities every day, keeping my focus on doing those things that I love.


(And thanks to Susan Piver for this lovely thought that was perfectly timed for my post. THIS is why we keep doing the hard and meaningful things.)



September Reading Round-up

Sincere apologies for another blog gap.  Time was an issue.  An update that failed was a bigger issue- I had to figure out how to restore the back-up, which was a bit of a challenge.  We appear to be live again, so here we go!

In JAMA this week, an interesting Viewpoint about developing a national trauma system that can achieve zero preventable deaths after injury.  It’s a lofty goal, to be sure.

I had the privilege of meeting Dr. Elmore, the first author, when I visited Wash U last year.  This study on trainee burnout in general surgery is important food for thought for all of us. She’s asking some important questions.

Small bowel obstruction is a bread-and-butter issue in general surgery.  Apparently, outcomes are best for patients with adhesive SBO who are managed by a surgical team.

Cultures that are driven by shame are cultures in which connection cannot occur- and in which we all tend to think that bad things are only happening to us. My own experiences during the hard times of residency tell me that the authors of this study are right– that connection AT work is as important in mitigating burnout and improving resilience as our activities away from work. When times get hard now, it remains true. Many of you know of my love of Brené Brown’s work, and this quote applies here: “If we can share our story with someone who responds with empathy and understanding, shame can’t survive.”  Yes.  This.

Recent pleasure reading that was discussed at book group last week was Outline by Rachel Cusk. It’s written in an interesting style and without terribly likable characters, though I’ll admit that the writing is excellent.  3 stars.

Happy September!  Happy Fall, y’all!



Reblogging: Second-guessing the 2011 workhour restrictions

Sarah B. Bryczkowski, MD¹; Amalia Cochran, MD² ¹ Rutgers, New Jersey Medical School ² University of Utah, Associate Professor, Department of Surgery The FIRST Trial: The FIRST Trial, or as it is officially known, the National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training, was published online in the New England Journal of Medicine on […]

via The FIRST Trial: Second-Guessing the 2011 Duty Hour Restrictions — Academic Surgery – Jersey Style