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.

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(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

Rites of initiation

“I’m not sure why they even gave you a spot in the medical school class.  That was a waste.”

Since it’s the third Tuesday of the month, that also makes it time for Schwartz Rounds at the University of Utah. Today was a topic that ties back to my research and informs the culture that I strive for us to create in healthcare- hazing in the healthcare hierarchy.

Mistreatment is something that is real within the educational process, particularly for young physicians, because of the hierarchies that exist in healthcare.  While the language that is most often used is that of mistreatment, use of the word “hazing” paints a more dramatic but no less accurate picture of what happens when these power inequities are abused.

Overheard at the nursing station: “You must be the stupidest intern ever!” 

Hazing Is: “Any activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers them regardless of a person’s willingness to participate.” I’ll grant that in the healthcare context we’re not talking about making someone drink themselves into oblivion or get their pledge signature book filled, but if we embrace the idea that hazing involves disrespect, that it infringes upon personal safety (physical or emotional), and that it fails to serve the purpose of the greater organization, we can all probably think of some examples from our workplace.  And when we put those into the context of how harshly we judge fraternities, sororities, or athletic organizations that haze, we get uncomfortable quite quickly.

Most hazing behaviors in healthcare- or mistreatment if that makes you less squeamish- are a historical holdover. “Well, it happened to me and I’m a better doctor for it, so it’s okay” is a statement I’ve heard more than once from a resident or student who experienced verbal abuse from a faculty member.  While it may be true that they did learn something from a public berating, the reality is that it’s unlikely to be durable learning because it preyed on their sense of shame (unhealthy motivator) rather than a sense of guilt (healthy motivator). Until we both name it and stop excusing it- and recognizing that it is NOT harmless to our trainees’ mental health- hazing is not going to slink off into the dark where it belongs. Let me clarify my point: It is NOT okay.  End of discussion.

I’m too busy to teach you today in clinic.  Can you just go get us all some coffee?

One of the reasons that hazing happens is based upon an idea of weeding out the weak. If you work in medicine, regardless of your team role, you already know two things for sure:

  1. Medicine is hard. We all do lots of hard things every day. We don’t need to make it harder.
  2. Entering a career in medicine already has a high bar, and if someone is truly “weak” they’ve already been culled.  Yes, there are people who are a poor fit for certain specialties; the likelihood that they are weak and need to be taken out of the herd entirely is inordinately low.  It’s also not one individual person’s decision to make.

I trained in a time (pre-workhour restrictions) and in a specialty (surgery) that weren’t known for kindness. In spite of that, I can’t look back at my training and call it malignant.  I’ll confess that as a 2nd year resident I was found crying in the corner of the SICU one day, and when the pharmacist who found me in that condition asked me what was wrong my answer was simply, “I’m tired of people being mean.” I’m also certain that in the sleep-deprived state of some of my training years there were days when I was one of those mean people (and if you were on the receiving end, I am still truly sorry for that). Overall, though? I was generally treated well by people even if the system wasn’t designed around kindness.

I’m fortunate to be at a point in my life where it’s a priority to me to lead within a culture that doesn’t tolerate meanness/ mistreatment/ hazing for its own sake. The negative things that happened to me weren’t necessarily right, and it’s my responsibility to not pay them forward. We all owe kindness and respect to one another as humans who are being.

“You seem like you’re struggling right now.  Let’s find some time to talk about it so I can figure out how to best help you.”

Yes.  That’s better, isn’t it?

Routine Vs. Ritual

Confession: I have a strong tendency to rebel against structure; structure and order simply are not my default modes of living and working.  Yes, I’ve learned to do work within structure and in a way that is orderly, though that is primarily a way of controlling the chaos.  If you look at my weekends when I’m truly off, about the only things you’ll find on my calendar will be “run” “yoga” and (during the appropriate season) “symphony”.

Someone recently observed that I’m reliable about getting my runs in, about writing, about walking Olivia, about going to yoga, amongst other things, and that demonstrates that I am committed to structure and order.

I, of course, argued against that idea, with my argument founded in how I differentiate routine, which is definitely about order, from ritual in my day-to-day life.  See, a routine is defined by pattern and regimen, and it’s characterized by a certain ordinariness (drudgery even?). Routine is doing the dishes after supper, or putting the recycling can out on Sunday nights. Routine is that weekly meeting that you are obligated to at work.  Routine is fixed and rigid, and I had a moment of joy when I saw that Merriam-Webster defines it as “a boring state… in which things are always done the same way.” Routine, in my mind, is obligation.  It’s the “must do” stuff.  It’s what sometimes gets referred to as adulting, which is an activity I’ve come to realize is completely overrated.

Why do I think of ritual differently, when it has some of the same characteristics in terms of patterns? Ritual’s word root is shared with rite, which has a spiritual or religious overtone. It’s more ceremonial, and rites can be part of a celebration. If you look at those habitual things that I’m reliable about, they are things that bring me joy, that I don’t consider drudgery (okay, there’s that rare run, but generally speaking…). They are activities that leave me feeling better than when I started them, that often challenge me, that are the foundation for (hopefully) making me a better version of myself. While I still tend to treat them as obligations, they aren’t the obligations that I see on my calendar and start secretly hoping that they’ll be cancelled.  Yes, there is structure around running on Saturday mornings at 7 with my running tribe, but there’s no question that it’s a challenge that I love. There’s structure around hurrying home after my run for a quick shower and snack before Restore Yoga, but there’s no question that I always leave yoga feeling better than when I got there. There’s structure around walking Olivia every single morning when we get up, but there’s such shared joy in our outdoors time together that I would be foolish to not be part of it.

I suppose the challenge becomes in trying to turn some of those routine things into ritual, which is entirely about changing mindset. Maybe tomorrow I’ll look for some joy in doing dishes…

 

I’d like to phone a friend…

This piece in WSJ this week generated quite a bit of conversation on Twitter within my circles.

You see, at times there is still this culture around the idea of calling for help being a sign of weakness.  I still know of too many faculty (because more than 1 is too many) who have reputations for being bears when called in the middle of the night- a reputation I consider only slightly more favorable than those who are known for ignoring calls and pages outright. And I still remember what it can be like to be on the resident end of those phone calls; you know that you’ll get berated for calling, but you also know that you’ll be in even deeper trouble if you don’t.

Teaching our trainees to call us for help is important, both for them and for the patients.  The trainees need to feel supported and we have an obligation to the patients to direct their care.  Residents shouldn’t expect to be spoon-fed, and I know that most of our residents will tell you that the first question I’m going to ask after, “What can I do for you?” is going to be, “What would you like to do?” because I still want them to be problem solvers.  I just want them to know that they have a safety net, which results in the last question I often ask: “Do you need me to come look with you, or are you okay?”

An important piece that extends beyond training is by calling for help when we’re concerned that we are getting into a bad situation. When I was freshly out of training, I didn’t think twice about calling my senior partner to look at things with me in the OR.  I can only think of once the he scrubbed in; more often he gave me someone to bounce ideas off of, and he validated that I really did know what I’m doing.  In the last 6 months, I’ve called one of my partners for help in the OR when I had unanticipated and impressive bleeding while doing a trach (he scrubbed, we fixed the problem together, patient did okay), and that same partner called me to look at a patient’s wounds with him intraopratively when he had concerns. I recognize that this is part of the culture that we have within our practice group, and I’m grateful for it; it supports us in making the best decisions for our patients and providing them with the very best care possible. And, as was astutely pointed out by a former student who is now a surgical attending, we’re providing good role modeling for our residents and students that calling for help is, in fact, the right thing to do, and that you’re never too senior or too experienced to invite someone else in to a complex situation.

While I value the culture that the Harvard hospitals are promoting around calling for help, I worry that the “card” described in the WSJ piece may be a bit too directive.  I can think of many scenarios that don’t necessarily fit the items listed and in which a trainee might wonder if they should call.  Ideally, they need to add one more item:

If you think you should call, call.

(Or, as I explain it to our residents- I’ve never gotten upset with someone for calling.  I have become very upset with someone for not calling when they should have.)

 

Do you hear what I hear?

Listen.

What do you hear around you right now?

I’m standing in the Sky Club in Atlanta on a day of complete travel meltdown for Delta, and here’s what I hear around me right now:

  • Some dude-bro behind me on the phone having a conversation I don’t understand most of.  Yes, it’s in English.  Sort of.
  • A low-level cacophony of other voices from all over the room.
  • A three year old telling an awesome story to her Mom.
  • Ice being scooped into glasses at the bar.  Glasses clattering.
  • Flip flops and luggage wheels of someone walking by.
  • Jet engines.
  • Laughing teenage girls over in the corner (see, the flight delays are fun for SOMEONE!).
  • Rustling of papers.
  • Clicking of the keys on my computer keyboard.
  • The “meep” of desk agents checking people in.

I try to do something like this as an exercise at least once a day by really focusing on all of the sounds that I hear around me. It’s often something I do in the mornings when I’m out walking with Olivia, and I do consider it a form of meditation to just focus on all of the sounds that are there.  It forces me to really, deeply listen to what is going on around me.

It’s want to believe that deep listening in my environment is transferrable to those times when I need to have serious conversations, be it with colleagues or with patients and families. It forces me to focus on that one sense and on the things that are around me, and when I’m in a quiet room with one or two other people, it allows me to move past all of the possible distractions that are out there.

We all have heard so much advice about how to be a great listener (in the interpersonal sense), and a recent HBR article indicates that pretty much everything that we’ve all learned is just plain WRONG.  Good listening involves asking critical questions, building self-esteem, having give and take, and making meaningful suggestions.  That idea that you get to passively nod and smile and be considered a good listener?  Nope.  It’s not that at all.  It’s much, much more challenging than that because it requires not just listening but communicating effectively.

One of the aspects of the article that I particularly appreciated was the idea of levels of proficiency in listening. Since we all almost certainly overestimate how good of a listener we are, the levels in the article give us a guide for our listening aspirations.

And perhaps the one piece of advice for Level 6 is the most important part of being a good listener- it is NOT about you.  Easy to say, and again, hard to do.

I challenge you to listen differently this week in just one little way.  Maybe it’s ignoring your phone while you’re in a meeting or having coffee. Maybe it’s staying curious about something you are being told and being brave enough to ask a question. Maybe it really is “just” listening and expressing support for someone in a challenge they want to take on.

And that listening exercise we started with?  Highly recommended. It can be fascinating.