May 2017 Reading Round-Up

Brand new month!

So what’s out there that is catching my eye?

We all spend quite a bit of time thinking about how to improve teaching of technical skills.  What about using video-based coaching to supplement OR teaching?

What does the public know (and want to know) about overlapping surgery?

The 2016 State of the Science articles for burn care are out. These cover everything from burn resuscitation to community reintegration, and are all important comments on where we are in burn care (and how far we have to go).

And bringing out my inner policy geek, here’s a great overview from Politico on what the impact is for the GOP if/ when Obamacare repeal fails.

Catching my ear is the “Up First” podcast from NPR. I seldom have time to listen closely to the news throughout the day, so this is a great summary of what’s happening.

Happy reading (and listening).

 

 

What if it’s not our fault?

“If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so weave a less arbitrary social fabric, one in which each diverse human gift will find a fitting place.” – Margaret Mead

In the last week I have found myself in the midst of two interesting Twitter conversations, both with a similar underlying theme regarding the impact of culture and how we seem to underestimate its impact on the individual.

Here’s conversation #1 (remember to start reading at the bottom):

I particularly loved the empathy behind the idea that the term burnout implies that it’s a personal choice. While we’re getting smarter about identifying organizational factors that drive burnout (ahem…my group’s call schedule), there still seems to be this idea that if you’re struggling with burnout, you’re simply not resilient enough. Reality check: I’ve witnessed some people who are remarkably resilient struggle with burnout, and without exception they have been in a work environment in which they had little to no control. Yes, I understand that individual characteristics may predispose people to burnout or may limit the impact of a dysfunctional system upon the individual…but at the end of the day, victim blaming and pretending it’s ALL about resilience?  That’s simply feeding the dragon.  It’s not helpful.

On to Twitter conversation #2:

(The link that you can’t see from here is this recent piece in the Atlantic.)

So, maybe it’s not about biological clocks or because we’re not ambitious enough.  Maybe, just maybe that ambition is situational…and that if we’re in an environment where we see other women hitting their heads repeatedly against the glass ceiling,  or we experience that ourselves, we adjust our expectations accordingly. Or we leave when we realize that we shouldn’t have to adjust those expectations because there isn’t anything wrong with them.

It’s time to stop telling us to try harder, or telling us that we can’t be mothers and academic surgeons, or telling us that we don’t measure up because we don’t know the 100 extra double-secret and unwritten criteria that you’re using to evaluate us. Most importantly, it’s time to create a culture in which we feel valued and supported, not because you tell us that we should, but because we actually are.

What if it’s really not our fault?

Why teach?

This past week was Surgery Education Week, the annual joint meeting of the Association of Program Directors in Surgery and the Association for Surgical Education. It’s a meeting that I first attended in 2001 and I haven’t missed a year since. I say that not as a point of boast, but to highlight my enthusiasm for this meeting; a week with people who share a passion for all things surgical education is professionally reinvigorating.  This year it definitely happened at the right time for me to get my bearings back.

My friend Chris Brandt was our ASE president this year, and he delivered a personal and heartfelt Presidential address on Thursday. Within the context of his speech, he asked an important reflective question for me as an educator, and one that I suspect will resonate with many of you:

“Why teach?”

Some of us fall into teaching semi-naturally; for me, it started with Vacation Bible School and helping in preschool Sunday School while I was still in high school, then teaching preschool part-time for part of College.  I  taught while I was in graduate school (if you haven’t read Dr. Seuss’ Butter Battle Book, you obviously weren’t in one of my international relations sections), and the one thing I knew in medical school before I was certain that I wanted to be a surgeon was that I wanted to teach.

But why?

For me, it’s the idea of paying it forward.  I’m certainly not going to wax philosophical about how every single teacher I’ve had has been amazing- that would be a flagrant lie. That said, I can tell you about my teachers who really made a positive difference for me. Steve Hoemann (English, 7th Grade). Carole Buchanan (World History, 10th Grade). Louise Bianchi (Piano teacher, 9th-11th Grade). Claudine Hunting (French professor, Undergrad). Mike Ward (Advisor/ International Relations, Graduate school). Jim Knight (Leadership in Medicine, Medical School). Danny Custer (Pediatric Surgeon, Medical school- I “blame” him for my career in surgery!). There’s one common thing that each of them did and that I value immensely: they made me better in some way. I know that I would not be who I am doing what I do in the way that I do it without this group of people, only two of whom actually knew each other. I also know that I am fortunate that they believed in me enough to challenge me, enough to push me out of my comfort zone, because they saw potential.

Why teach?

Because now it’s my turn to find that potential in learners, to nudge them out of their comfort zone, to help them be better.

Besides, the emails and notes that you get for this are pretty awesome. I can’t read any of them without smiling and thinking, “THIS.  This is why we put in the extra effort, the extra thought, the extra time.”

So, what’s your story? Why teach?

A slightly belated April reading round-up

I’ll start with an apology: I’ve not been on my A-game with keeping up with the blog lately. Lots of life distractions, many of which I’m hopeful will start to settle down soon.  It’s not been easy.

So, it is April, and a number of things out there have caught my eye.

The March print edition of JAMASurgery included this systematic review and metaanalysis of causes of attrition in general surgery residency. While I’m reasonably certain we can’t get the rate to zero because there are factors we cannot control, we must do what we can.

While we are all becoming painfully aware that too many narcotics are being prescribed for our patients, we tend to not have a good understanding of what constitutes too many or too much.  This study provides an important baseline for us as surgeons. I will also note that Annals of Surgery will have an ongoing series examining the opiod crisis from a surgical perspective.

We’re definitely talking more about delirium mitigation in our adult ICU patient population.  What about the children?  Apparently it’s a problem for them too (particularly with “inflammatory disorders,” which would definitely be my patient population!).

Going a bit outside of the medical journals, what’s next in hospital innovations to keep patients safe? I was thrilled to see my friend Amir Ghaferi‘s name as first author on this piece.

Pleasure reading?  Our book group is spending the next two months with one of my all-time favorites: The Amazing Adventures of Kavalier and Clay by Michael Chabon.  I am looking forward to re-experiencing it.

 

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.)