We’re all experts now

Or are we?

For my medical friends, we see it in the American patient predilection for paging Dr. Google. For those of us who follow the environment, we see it in the denial of climate change. And we ALL saw it in the 2016 election in the form of the echo chambers on both ends of political spectrum.

What is “it”?

Confirmation bias- that big, bad cognitive stumbling block that allows us to completely ignore information that doesn’t support our ideas/ opinions/ “facts”. Our brain is amazingly gifted at dispensing with inconvenient information, and confirmation bias, and neuroscience shows that we tend not to look for information that challenges our beliefs.

Think about that for a moment. When is the last time that you actively sought information that doesn’t align with something that you believe about the world? Be honest here. Oh, and think about how much you learned the last time that you did make that effort (because we know that confirmation bias limits our learning!).

It seems that the current political and social environment in the US has resulted in a flurry of writings about confirmation bias, particularly its impact on science and policy. While confirmation bias used to be a phrase that we mostly used to describe a failure to maintain equipoise as an investigator, it’s become a key part of the 2017 lexicon, particularly with the advent of terms like “alternative facts.” I have to admit that I’m not sure I feel any safer about people embracing alternative facts when we know that facts don’t change our minds.

Another often underestimated aspect of confirmation bias comes from deeply held personal values. Be it the risks vs. benefits of drilling for oil in the Arctic or how Planned Parenthood actually spends taxpayer dollars, many individuals have values-driven opinions that impair their ability to have meaningful dialogue around these topics (myself included at times). Instead, everyone fancies themselves an expert on topics that they aren’t, and instead of intellectual, meaningful dialogue we get meaningless and unhelpful shouting matches. Suddenly we’re back to that echo chamber of the 2016 election…

The medical tie-in for confirmation bias is, of course, when it impacts our diagnosis and management of patients. (Note: if you haven’t read Jerome Groopman’s How Doctors Think and you are in the medical field, you are doing yourself and your patients a disservice.) Certainly we base a great deal of what we do upon pattern recognition.  But what about those times when the patterns lead us down a primrose path that is…wrong?  It happens, even to fabulous clinicians.

How do we overcome confirmation bias if it is so insidious?

Simple.  Seek proof that what you’re thinking is a terrible idea.  Look for disconfirming data. Conduct small experiments that are capable of disproving OR proving that your idea is right.

In other words, prepare to be wrong from time to time.  It’s part of our human experience.

Ladies, get yourself a Girl Gang

I admit that I usually try to give you food for thought then let you draw you own conclusions and applications.

Tonight, on the eve of International Women’s Day, I’m making an exception.  I’m dispensing some invaluable career advice for my women readers, particularly those in surgery:

Get yourself a “Girl Gang.” If you are somewhere where one is already in place, find out how to become a contributing member. At all costs, though, find yourself a group of women who share your commitment to excellence.

This article examining mentor-mentee sponsorship and gender came to my attention over the weekend (HT: Susan Pitt).  She astutely pointed out that this gives us an “action item” for women in surgery- to do a better job with sponsorship as more of us move into leadership roles.

This came on the heels of my friend Harriet Hopf mentioning during a breakout session last Friday that she appreciated being asked to join a “girl gang” that we already had in place at Utah with the expressed goal of promoting one another for leadership opportunities and awards. She came here from an institution with plenty of women in her department and in leadership roles, so this wasn’t something instinctive for them to do. For those of us in departments and places with a paucity of women leaders, it’s critical.

How does our Girl Gang work?  It’s remarkably easy.  We watch out for leadership positions or awards (both within and outside of our institution) that align with one other’s skills and accomplishments, and we nominate each another. Also, if there is a recognition that one of us really wants, we have an understanding that self-nomination to another group member is encouraged, and they’ll take care of the actual nomination.

Certainly our effort focuses on a group of women who are at a certain stage of their career, and those people definitely comprise the active members of our Girl Gang. However, once you start doing these things for your peers, you realize that it’s easy enough to extend your influence beyond that core group. I suspect I’m becoming a bit notorious with some of our female faculty in particular for my “nudge” emails (“You are incredibly qualified for this…you should apply…how can I help?”). My basis for doing this is two-fold, and both are factual.  First, as women we tend not to apply for things until we’re overqualified.  Sometimes we just need someone to tell us that yes, we really are worthy.  Second, it helps take the stigma away of tooting your own horn– again, something that women are penalized far more heavily for than are men.

(Closing note: While our Girl Gang has focused heavily on promoting the careers of women, we are not exclusionary and we welcome allies. I solemnly promise that I’ve put men forward for awards, leadership roles, opportunities, etc…I just focus on it less because we’re nowhere near having a critical mass of prominent women in academic surgery.  Yet.)

March 2017 Reading Round-Up

Ah, March.  Here you are, and you didn’t even come in like a lion.  Thanks for that.

First, more information confirming my own bias that communication with our patients and families matters, not just for the fundamental “it’s the right thing to do” reason, but because it also impacts risk of postoperative complications.

This terrific Perspectives piece discusses the role of trainees in the changing medical care landscape in the US.

As my own team works to identify risk factors for delirium in Burn patients, this article with risk factors following colorectal surgery may provide us with some guidance.

Were you there for my friend Mary Klingensmith’s fantastic ASE Presidential address last April?  If you missed it (or if you were there and loved it), here it is in print.

Side reading: February’s book group book was Alexander Marra’s The Tsar of Love and Techno. VERY highly recommended.

Greater than, less than

“Who and what do societal and cultural institutions tell you that you are?” HT: Desiree Adaway

This question came across my Facebook feed this morning; in truth, Desiree Adaway posts provocative thoughts on a daily basis. The timing of it mattered because my thoughts have been marinating about a social media storm that happened last weekend and they have finally (mostly) become coherent enough to share.

I’m going to give the short version of what happened last weekend without any screen shots, mostly in the interest of not resurrecting the whole thing AGAIN.  Here are the key points:

  • White cis male surgeon posts an irrelevant and incredibly sexist response to an article on Doximity; he apparently thinks that his response constitutes “humor”.
  • Outrage follows from many women surgeons and male allies. Outrage includes LOTS of Twitter bandwidth and screenshots being shared of his comment with his identity. Outrage also includes people identifying his Twitter accounts and putting comments/ ratings on his practice social media sites.
  • Questioning of the level of outrage occurs with concern expressed that “this could ruin his practice”. Response from those involved is essentially that he earned the judgment.

Other than expressing my horror at his remark,  I largely stayed out of the fray because I couldn’t get entirely comfortable with what any further response should be.  Some of my colleagues provided thoughtful and eloquent responses on Doximity on the thread in question.  One colleague with a significant social media presence actually tried to reach out to him (I don’t know if she was successful or not). A colleague who pled for those who were publicly sharing his information to be thoughtful seemed mystified by the backlash.

And, towards the end of all of this social media hurricane, I hope I was able to crystallize many of the issues into one thing:

The comment implied to women surgeons that we are “less than” in some way.  It’s an experience that has happened to nearly all (if not all) of us at some point in our career-  we have been told, either implicitly or explicitly, that we aren’t as good, aren’t as qualified, aren’t all that merely because of our gender. For our women colleagues who are racial and ethnic minorities, they often are told that they are “less than” twice- once for their gender, and again for their skin color.

The truth is that unless you’ve been told that you are “less than” it’s hard to internalize what that experience is like.  The truth is that when you’ve fought your entire career to not be “less than” (which has often required being “greater than”), that yes, you are going to be outraged when someone publicly indicates that simply by virtue of your chromosomal makeup that you are “less than.” The truth is that many of us are tired of those messages of being “less than,” and we’re simply not willing to put up with it anymore- either for ourselves or for those around us. It’s not cute, it’s not funny, and it’s simply not okay.

Lest you think I’m trying to justify the public shaming that occurred, I’m not, because I’m still ambivalent about parts of it.  What I am trying to provide is a window on why the response was so furious for those who don’t get it. It’s only partially about the one statement, which reflects anywhere from years to a lifetime of messaging that we’re simply not willing to tolerate anymore.  Neither should you.

 

Don’t be cruel

While none of us are eager to admit it, many of us have witnessed bullying in the healthcare environment. Sometimes it’s senior physician versus junior physician or medical student. Sometimes it’s physician versus nurse. Almost invariably it involved the presence of a power differential, someone who is advantaged versus someone who is not.

This past week, this podcast was released as part of the JAMA Podcast series.  If you’re not familiar with the JAMA Podcasts, they are pretty terrific.  In this one, Ed Livingston cites much of the data about the prevalence and impact of abuse/ bullying, with a particular focus in this podcast on medical students. If you want background reading for the podcast, the original case and discussion are here.  I want to highlight the importance of ignoring behavior like that described in the podcast (as do Dr. Lucey and Dr. Livingston)- if we ignore this behavior, we’re implying that this is okay.  Note: I am particularly heartbroken by the surgeons who were so terrible to the medical student- I promise we don’t eat our young. Also, if you’re in training as a student or resident and have someone in a position of power who is bullying you, it’s likely not just you they are picking on…find someone safe to report it to who can hold them accountable.

Interesting timing of course means that during the same week something came across my email talking about how to overcome bullies at work.  An important point that he makes is at the very end: If you’re surrounded with jerks, you’re at higher risk to become one.  Choose your environment wisely. (((Related but unrelated: some of you have heard me talk about Eric Barker’s blog in the past, and this piece is no exception to his usual brilliance.  I try to subscribe wisely to things, and his weekly blog is a highlight in my email inbox on Sundays.)))

And what if this isn’t about a power differential, but is more about a peer who is a jerk when they aren’t being watched? Remember not to get hooked, and that it’s really not about you.  Then refer back to the prior piece.

 

 

 

 

Wasting of time sitting still?

I’ve made a deliberate effort of late around the concept of mindfulness and of trying to be more present.

In other words, I’m trying not to engage as egregiously in zoning out and checking email and catching up on Twitter when I’m supposed to be paying attention.  Meetings are, of course, a special kind of danger zones for these things. So are completely overprogrammed days, when my entire schedule consists of running from Point A to Point Q to Point L, with no breathing space available and…when was I supposed to have lunch? Days like those are the days that stress me out.  It’s not that I can’t handle the day itself.  It’s that when I’m doing all of the to and fro, I lose the ability to manage my energy.  And when I lose that ability to recharge, even if it’s only for 30 minutes a couple of times, I know I’m not at my most present.  I also know that I get grumpy.

When I “check out,” when I start that multitasking, there’s clear evidence that I’m probably making things worse rather than better (ladies, the link applies particularly to you).  And while I wasn’t successful in keeping it controlled the entire day, late in the day I was cognizant enough to start using the, “Right now, it’s like this” framework to remind myself that days like these are truly exceptional.

Today’s tactical error that I know has been helping of late? I did NOT sit for 10 minutes this morning prior to getting the day going (though, to my credit, I didn’t start with email either).  I’ve learned that 10 minutes of sitting and just breathing after the alarm goes off helps me to feel like I’m setting the tone of my day rather than having it set for me.  Even with that knowledge, after a late evening and with an early morning I skipped it.  Not a great choice because I’m learning that it’s a total set-up for distraction for almost the entire day- or at least the parts when I can be distracted and not seem completely inappropriate.  The day took control of me.

So tomorrow, I’ll sit again for 10 minutes when the alarm goes off (with a purring cat in my lap if I’m really fortunate). That’s the part of it all that I can control, and it lets me set the tone to make the rest of the day go more smoothly afterwards. It’s not like the day was a wholesale disaster; if anything, it all ended up fine. It’s just that process, being present and engaged through all of it, could have been less bumpy. I’m grateful that I get the chance to reflect and do better.

And if you’re looking for ideas to help you be more mindful at work, I am particularly fond of this list.

Sitting still?  Apparently not a waste of time at all.

(And for those who may have caught the slightly obscure musical reference, you’re welcome.  REM from 1984 is as good now as it was then.)

 

Reading-Round Up, February 2017 edition

As promised, here’s the February reading round-up.  What’s caught my eye recently?

I was at SCCM two weeks ago, and would encourage anyone with an interest in critical care to read the Plenary Articles published in Critical Care Medicine.  These presentations at the meeting were all nothing short of amazing.

And… the Sepsis Guidelines have been updated (note: it’s mostly tweaks, little that’s entirely new).  If you’re not a critical care doctor, this is still important and relevant if you want to provide evidence-based best care when your patient has something go wrong.

In surgery we sometimes get to have conversations with patients and families when we don’t anticipate a completely smooth clinical course.  I’ve been playing with this framework since Gretchen Schwarze came and talked to us about it last year, and I find it helpful.  You might too.

Here’s some background work (with more great work coming) from my colleague Chris Pannucci on Anti-Xa level monitoring and perioperative use of enoxaparin.

Last year at the ASE meeting I was a little dismayed to find the frequency with which medical students use Wikipedia as a reference during the clerkship.  This article provides some justification for simply embracing it and makes me question if we should have a Wikipedia “hackathon” during 2018 Surgery Education Week.

I’ve preached about the importance of allies for women in male-dominated fields before in this blog.  Here’s another confirmatory article from HBR. Men, we really need your support, and if done right we can even benefit from your leadership.

Happy reading, all.

I was a stranger and you invited me in

Although I usually don’t go clearly political around here, it’s happening today; since it’s time-sensitive, I interrupt your regularly schedule programming. Your February Reading Round Up will happen over the weekend, I solemnly promise.

I’ve spent almost a week now pondering the Executive Order issued last week that limits entry to the US by residents of seven Muslim-predominant nations. When I first read about it on Friday, I immediately thought of two former medical students I mentored whose parents immigrated to the US from Iran in the late 1970s under terribly unfavorable conditions. I thought about a young Iraqi who we cared for during my time at Shriners as a fellow. And, of course, I started thinking about many, many immigrant stories of friends, colleagues, and my own family and the impact that blanket policies could have had on many of us.

Of course, over the last week many stories have come to light.  The first one I saw was on Facebook– an Iranian woman with a PhD from Clemson who went home to visit family, then couldn’t get back to her home in South Carolina.  She astutely asked what happens to her car at the airport, to her house filled with her belongings, to her dog? That brought the immediate human cost home to me.

Then there’s the story of this Sudanese physician, training at the Cleveland Clinic, who was in Saudi Arabia on vacation with her family when the Executive Order dropped. She is now suing. She is not alone in this.

For those who don’t know, many foreign medical graduates come from the targeted countries, and many of them are delivering healthcare in areas where we simply can’t get American physicians to work.  Not only does this affect that pipeline, it also may impact their willingness to come here in the future if it becomes easier again.

Most importantly, it appears that the foreign docs we are attracting are the best and the brightest since Medicare patients cared for by IMGs have a better in-hopsital survival rate.

The AAMC and the ACGME have generated thoughtful statements on the impact of this Executive Order on medical education and healthcare delivery. I particularly appreciate the ACGME for acknowledging the associated moral distress around the order; this has been an almost taboo subject, but it really shouldn’t be. This order has real human consequences on scientists, students, and residents; on patients; on families; and on the American healthcare system as it currently functions.

What’s my point here? Simply that this Executive Order appears to have had plenty of unintended consequences.  It wasn’t ready for prime time, and it became clear over the weekend that ICE and DHS weren’t ready for implementation.

And my other point is simply that it’s easy for us not to know all of someone’s story and how they can be impacted by decisions that seem less-than-strategic when you look at all sides. I’m not going to make an argument for wide-open borders, but for us to be able to help people who are trying to help people…well, that seems like the right thing to do.  It also seems, to me, to be relatively apolitical.

 

 

 

Starting them young

How many of you saw this study about emergence of gender stereotypes and intellectual capacity that came out on Thursday?

Actually, let’s roll back to two years ago when the same group published this study on expectations of brilliance and their relationship with the number of women in scientific fields.  The summary is that fields perceived as requiring brilliance or genius tend to be male-dominated, while fields requiring hard work and empathy have better representation of women.

I’m grateful that the authors went back in to try to figure out when this happens; apparently, it’s somewhere between kindergarten and first grade, give or take.  Girls start picking up social encoding that boys are the ones who are “really, really smart” and the logical side effect of that is that girls stop pushing themselves to do those things that they think require being “really, really smart.”  I suspect this happens in a variety of ways- through the media, through acculturation, through implicit bias.  While I didn’t get messages at home that girls couldn’t be “really, really smart” (in fact, quite the opposite as I took everything in the house apart and climbed trees while wearing dresses and wasn’t told that girls weren’t PresidentSurgeonCowgirls), I definitely suffered bias at school in math.  Every time we would move- which was frequent as evidenced by 6 elementary schools in 5 years- I would get put back to grade level in spite of documentation that I was usually 2-3 grade levels above.  In hindsight, I have to ask, “Would that have happened if I were a boy?”   The reality is that the answer is, “Probably not.”

The bigger thing (since y’all know I try to be solution focused around here!) is to think about ways to (1) inoculate our girls against this and (2) “rescue” those who are already older than age 6.

The BBC published this helpful guide the day after the Science study dropped last week.  There’s a reference in there to A Mighty Girl, which you can also follow on Facebook.  I’ve followed them for a while, and even being a few years older than 6 routinely find their posts to be inspirational. We need to focus on the importance of doing hard work that we’re passionate about, regardless of gender. We need to remind each other when we’re doing hard things well and having brilliant ideas.

Now, let’s all go out there and bust some assumptions, shall we?

One…more…thing!

This past week I attended the Society for Critical Care Medicine Critical Care Congress.  Sure, the venue was a draw (Honolulu), as was the opportunity to spend time hanging out with my favorite pharmacist (Ann Marie is a rockstar and wonderful human). More importantly, I always leave this meeting feeling like it was time and money well spent.  This year was absolutely no exception (and yes, Burn Unit colleagues…be afraid.  I have at least 5 new and improved ideas for us!).

One of the standout sessions was a 2 hour discussion of burnout in ICU providers.  The session focused on physicians and nurses, and I’ll grant I would have liked more inclusion of information for our APCs, our PTs/OTs, and our pharmacists.  In spite of that, there was a lot of great discussion around the topic; if you want to see what it looked like on social media, check out the #StopICUBurnout hashtag on Twitter. It’s clear that we need to take a team-based approach to burnout because of the impact on team dynamics (it’s contagious) and patient outcomes (it’s negative).  Oh, and it also negatively effects our learners.

Here’s the conundrum around burnout.  A certain amount of stress can be positive and constructive under appropriate circumstances.  Plenty of  literature demonstrates that we adapt, both individually and collectively, with a certain amount of stress and that these changes can be for the better.  The issue becomes when the amount of stress is simply too much and we can’t manage another thing.

Like this:

Just right 👌

Posted by The Awkward Yeti on Wednesday, January 18, 2017

I’ve been there, and if you’re honest with yourself you’ve probably been there too. That’s when stress can become negative and maladaptive and push us into that “burnout” space.

What if going for a run or going to yoga or doing whatever your “thing” is- what if that were actually helpful even when you’re heading into what I’ve referred to more than once as “the land of overwhelm”?  Or…to ask it another way, how many times have you not done something that you know is good for your mind, soul, and body because you simply have too many other things to do?

Again, yes, count me amongst the guilty. But what if that “one more thing” is actually something that really is regenerative for you?  It might actually help you to become more productive and more focused.  And if you’re a leader in your environment, by being authentic and engaged (and less stressed), you’re setting the best tone for your team to thrive as well.

Try it.  Let me know how it goes.  I promise I’ll work on doing better with this as well.