Life in the Wild West

• Season change always reminds me that even though we pretend that time is linear (which is a Very European Concept), that time is also cyclical. And relational. I try my best to be on time, and I usually get it right. And most of the time when I don’t, it’s simply because I didn’t want to/ couldn’t rush through something relational.
• It’s been a bit over two years since the WHO declared us to be in a pandemic. Who knew that it would drag on as long as it did?!? Two weeks ago marked my first travel for a professional meeting since that declaration occurred. The good: It was amazing to see some people in person and spend time with some folks whose brilliance I find irresistible. The bad: I had a migraine after a long travel day with a late night. I’m interpreting that as I just don’t travel like I used to, which is honestly fair now that I’m in my mid-fifties. The curious: As much as I loved being back in a congregate setting, I’m realizing that I’m simply not willing to exhaust myself with my Spring travel shenanigans in the same way that I was even 5 years ago. TL,DR: I’ll be making strategic choices about April professional meetings going forward because there are, quite simply, too many of them.
• A colleague made my day on Friday when he mentioned a quote that I recently had on my office door because it helped him reframe…so I figured I would share it here. “Joy is the oxygen for doing hard things.” (Gary Haugen, with a HT: Kate Bowler) Or, as I’ve said for years with regard to running, I GET to do this. It applies to all areas of our lives.
• Confession: I finally have dug into why writing hasn’t happened as much as I intend, and I think I finally figured it out…writing (at least for me) is putting my voice out there. And when one writes on the stuff I tend to write on, it can be pretty vulnerable. I’ve not been in a space personally for the last couple of years (*before* the pandemic declaration, so don’t blame that unfairly) that I’ve felt powerful enough to share my voice. I think I’ve finally sorted through that fragile place and am ready to get my voice going again because I realize that it does matter. As Madeline L’Engle wrote, “Our truest response to the irrationality of the world is to paint or sing or write.” The world remains incredibly irrational, and I’m ready to respond to that again.

In the business world, the concept of “the first ninety days” in job transitions is nothing new. Unsurprisingly, this is a concept that has been top of mind for me for the last 90-ish days as I’ve settled into a new department and new responsibilities. I know I’m not the first to have a change like this and I’m well aware that I won’t be the last- but I did want to share what have been my guiding principles in navigating this critical time.

• Boozhoo– I learned about this important Anishinaabe concept reading for my graduate work last year. Simplified, it means we have an agreement to learn from each other and we will respect each other. I more recently encountered it again introduced as “how to arrive”- and it truly is how we should arrive in a new space regardless of where we sit- or aspire to sit- in the power structure. Note: Eddy Rogers has a great TedX talk that starts with this concept, then moves into his own Indigenous journey to leadership. An important corollary to boozhoo is to remember that you are never too senior to shamelessly ask questions as you’re learning the ways and people of a place. If you can find a cultural interpreter to support you as you settle in, all the better.
• Names matter- I would argue that one of the single best leadership tips I’ve ever received is to learn the names of everyone who surrounds you and who works with you in any way (this applies to static situations as well as new ones). Think about how special you feel when someone knows your name, particularly when it’s someone who is advantaged in the hierarchy. In contrast, think about times you’ve had someone in power who has willfully failed to learn your name and how that made you feel. Learn EVERYONE’S name, and use their names in interactions. It’s a matter of simple respect. And for heaven’s sake, learn to pronounce their name correctly!
• Lead with gentleness and curiosity– It seems intuitive that you shouldn’t be a bull in a china shop, so to speak, and in spite of that I’ve seen plenty of leaders who are new to an institution and who come in immediately intent upon changing almost everything, and they’re unkind in how they do so. Generally the changes they drive aren’t sustainable. In the process, they alienate talented people who are already there and who have been working hard for a long time. Don’t be those leaders. In contrast, I have seen new leaders who have come in, listened intently, shared with kindness, and who have had an outsized impact in a very short time because of how they interact with people. Which way would you prefer to be remembered?
• It’s not a sprint– You’re not going to know your way around the building in a week, and you’re not going to understand all of the systems and people and history and interactions in a week either. As an almost lifelong distance runner, the idea of pacing is all-but-intuitive to me; I’ve run plenty of half marathons where I’ve seen people go out hot in the first 6 miles and I pass them up at mile 10 because they ran out of steam. If you’re planning on staying, you have all the time in the world to learn the intricacies of everything.

I know that none of these ideas are entirely novel, and I also know that none of them seem terribly complex. Three of the four are fundamentally rooted in being respectful to your fellow beings. And yet…they simply aren’t used as much as they probably should be.

Change is intrinsically hard. Hopefully these ideas make it a little bit easier.

I had no intention of turning the blog into a ghost town this year.

And yet…that’s what happened. Fortunately people still find it and read it and find things I’m pondering useful and helpful.

I’ve thought about writing here and simply haven’t done so. If I were an ambitious maker of excuses, I could provide more than a few (some would be real, some would be ridiculous). I do miss writing- I just haven’t missed it enough to get back to it. I’ve heeded my own advice about “What do I need right now? What in this moment will help me the most?”

In the last 90 days, I’ve moved my own household across the country (2300 miles if you’re keeping score). I’ve (mostly) wrapped up a consulting job I loved getting to do because it was to support people and a place that matter deeply to me (#becauseMontana). I’ve started my “next chapter” in academic surgery and have resumed being a clinical burn & critical care surgeon (sabbatical, I miss you, but Go Gators!). After 20 months of being without a dog, I now have a 6 month old Scottish Collie puppy (gratuitous photos and lessons learned from Rex to follow). In addition to my own move, I’ve dragged my dad across the country to move into assisted living 20 minutes from my home (y’all…aging parents are a THING. I now have plenty to say about that.). I’ve trained for a half marathon for the first time in 2 years (we’ll see how that training went tomorrow morning). I’m sure I’ve done a few other things, but those have been the ‘big’ things. Individually, any one of them is an accomplishment. I’m hoping I’ve stacked the deck in a way that I don’t need to have any other major life shifts for a good long while.

When I look at that list and think about my commitment to managing myself and my energy in a way that is kind, it’s easy to recognize I didn’t have much leftover to write with. I want to believe I have wisdom to share from all of these experiences and I’ve got a list of topics saved up to work from over the next several months. So stay tuned- there’s more where all of this came from in the first place.

I’ll close with a gratuitous puppy photo that emphasizes his “floof” around his ears and his Collie snoot. I promise he’s not always serious like this!

I’ve long believed that conflict, done well, brings benefit to an organization. I’ve become increasingly adamant about that “done well” portion of my premise over the last 5 years or so- perhaps because in various venues I have had the opportunity to see “ideal” conflict as well as witnessing destructive conflict. A few weeks ago this cartoon came across my Instagram feed (note: Liz and Mollie are fantastic!), and that nudged me to try to put together some thoughts to share on the topic.

Many of us have been conditioned, either by our families of origin or by society, to believe that conflict is inherently bad. Instead of cultivating healthy ways of disagreeing, we avoid it at all costs. Yet respectful conflict can actually make a meaningful difference in both our personal and professional lives. I’ve seen a description of the concept of acquiring conflict debt, which is the sum of all of issues that haven’t been discussed and resolved that stand in the way of progress. In workplaces or families with high levels of conflict debt, conflict is neither valued nor normalized; managing conflictual conversations cannot even occur in these groups until leaders recognize that disagreement can be beneficial. I’m unafraid to state that some of the most difficult leaders I have worked with or for have been those who are absolutely unwilling to address hard topics, particularly when that’s going to result in a disagreement. They end up leading teams that are stuck and stagnant and have a high conflict debt load.

Numerous benefits are known for teams who can disagree. We know that they perform better in complex problem-solving exercises. We also know that discomfort is inherent in having teams that are diverse, but when this is embraced that these teams are often “creativity catalysts.” The transparency that allows groups to grow using conflict strengthens relationships, and provides a skill set that can be transferred to other relationships. Ultimately, the willingness to work with discomfort is beneficially for diversity- it becomes a virtuous spiral.

Some of my friends get to hear me talk about a Board that I serve on because I often offer it as a model for how to do conflict effectively. The primary understanding between all Board members is that we care deeply about one another, and that we have respect for the skills and experiences that the other women present bring to the table. Because of (not in spite of!) that underlying respect and because we have a clear mission that is value-driven, we frequently do not agree about processes or tasks. When I first joined the Board, I immediately realized that our board President is a catalyst in our conflict process because she creates a space where everyone has the opportunity to be heard. What I have seen happen time and again is that because we all speak freely, we almost always create something far more powerful than any of the original ideas through our disagreements. Ideas are valued for their content and potential, not for who spoke them.

I’m hopeful that you’re curious about some practices you can use to improve your conflict skills. Certainly formal training can play a role; in the absence of that, however, here are a few principles that can be helpful.

-Recognize that you’re not always going to be liked. Importantly, disagreement doesn’t equal a lack of kindness- unless you behave in a way that makes that true.

-Work from a common goal and seek common ground.

-Stay curious! Conflict is a chance to learn.

-Get unstuck- ask the other party for advice or take a break from the conversation if it’s not going well.

I’m not advising that you should disagree simply for the benefits it can bring if you agree with someone, go ahead and do so enthusiastically. My goal is to make conflict a little less scary so that we can find ways to disagree without being disagreeable.

One of the things I have found fascinating during the pandemic is the more open acknowledgement of “hustle culture”; it appears that more people have started to have second thoughts about being always-on and always pushing. I’ll admit that my bias within this discussion is likely obvious with the sabbatical that I’ve been on since June of last year, which has had plenty of interesting lessons embedded within it. When I started on this, I certainly knew that I was desperately in need of down time, spiritually, intellectually and physically. What I didn’t fully anticipate is how challenging it can be to go from 100 miles a minute to…well, if I’m honest, it hasn’t been zero. Let’s say 15 miles an hour, like a moderately fast (for me) bike ride.

One of my earliest epiphanies last summer was how much uncompensated work we’re doing in academia on a routine basis. Article reviews, letters of support/ nomination, organizational work, mentoring, scholarly activities- all of these are things that are expectations in the academic world. And while I don’t question their relevance or importance to our professional community, what I realized is that we may not be rewarding them as completely as we should. I also realized that many weeks this year I’ve put in the equivalent of part-time work hours to all of those things; it also reminded me that when I’m in an academic role these are the things that move into nights and weekends and down time.

When we have things bleeding into what should be time for friends, family, hobbies, sleep, LIFE and when we don’t bother to question it, we’re buying into culture that encourages us to be always on. People in high-achieving professions are already predisposed to perfectionism and overachieving (I’m looking deeply at those of us who have been to medical school here, though I know we don’t have the market cornered on this); that mindset of always doing more and being more allows us to succeed and it gives us blinders to the harm we’re doing ourselves and those around us. We’re told we should be grateful for the opportunities, and while that isn’t untrue, too much of a good thing is no longer a good thing. I’ll be the first person to tell you that your body has the wisdom and power to tell you when you’re past time to stop; if you haven’t taken the time to rest, you’ll get the opportunity to be rested. And yes, that’s personal experience speaking.

I’m not here to tell you that achievement is a bad thing. Far from it- it’s how we change the world to make it into a place we really want to be. What I am here to tell you is that just like overtraining is a “thing” in fitness, it’s a “thing” in our daily lives as well. Rest is not how we’re programmed in modern American society, and it doesn’t align with the scarcity mindset messages that inundate us. I’ve recovered joy by having time to rest this year, and I’ve felt joy seeing reminders out there- particularly from members of historically excluded communities- that rest is a revolutionary act. And while it’s not incredibly practical to take months to rest, if we’re intentional about it we can rest and play most every day.

It’s Sunday morning, and to close my mini-sermon on rest I want to remind you of three incredibly important things:

1. There is plenty of everything to go around. Scarcity mentality is a lie.
2. You are enough.
3. You do not have to EARN rest. Go rest. Go do things that connect you to joy. Or do nothing at all, and find joy in simply being. There are no bonus points for exhaustion.

I think of rest a bit like I think of grace- it doesn’t have to be earned, but in order to receive it we have to be open to it. And we get to try, and try, and try again.

I spent the first few years of the 2010s doing research on disruptive surgeon behavior, trying to get a handle on what precisely it is and what its effects are. That work came to publication right around the same time as my first role as a Vice Chair of Education and Professionalism; when we were developing the models of disruptive behavior there was an undeniable impact on learning environment, so if I was going to be responsible for education I wanted to also have authority to address “bad behaviors” by those doing the educating.

I’m here to say I’ve learned a lot in these roles. I’m also here to say that while in 2014 I was proud to be in a leadership role addressing education and professionalism, I know also sometimes mumble the last part of that title (even though I had advocated for it). I naively thought that professionalism wasn’t a complicated concept- in my mind, it equated with creating spaces of psychological safety that positively impact both learning and patient care. Professionalism was being clear, communicating effectively and respectfully, working in ways that engender mutual support. Professionalism included exhibiting emotional intelligence and engaging in crucial conversations.

Being a Pollyanna can be such a delightful thing (and yes, if you are a student of the Enneagram, I’m VERY 7)…until it’s not.

Over time I’ve seen professionalism turned into a weapon in a couple of different ways, neither of which are helpful. In one version, the leader/ senior person uses “I was just taking care of the patient!” as their justification for behaving in a way that is decidedly not collegial. While that’s certainly logic that is hard to argue with, it’s a devious use of the concept of professionalism to focus solely on patient care through a lens of perfectionism. I’ve got no intention of diving into the psychopathology underlying perfectionism that shows up in this way, but I will say that it’s clearly intended to shame people into doing things. And, as we all know, shaming isn’t actually an effective teaching or collaboration technique.

I’ve also learned that professionalism can (and is) used against individuals who are members of historically excluded groups as a tool of conformity. Using voice and diction, hair styles, clothing choices (to name only a few options) as a basis for someone “not being professional” becomes incredibly subjective; in these cases, what it more often means is “this makes me uncomfortable because it’s not what I’m used to hearing/ seeing.” Professionalism has in many settings become an instrument of bias that is deployed by those who are traditional power-holders- and if I’m honest, it frustrates me that they choose to use it in this manner. I’ve never been a fan of power “over” relationship structures, particularly for something that is ideally a power “with” or power “to” concept.

I still believe that there is a concept out there that aligns with what I used to think professionalism was. I also still believe there can be a net benefit from systems and structures that are designed to enhance collegiality and interrupt bias. I’m just not sure what the word that describes it is anymore; perhaps it is still professionalism, and the idea needs to be reclaimed from the abuses that it has suffered.

Okay, this could certainly be a broader epistemologic question, but in this case I’m thinking more specifically about teams in health care. I love the fact that my clinical work in a highly interdependent specialty has allowed me to see some incredibly high-functioning teams AND some incredibly dysfunctional teams (I prefer being part of the former). Last summer I was asked to give a talk on breakdown within the healthcare team and chose to focus on the unique features of our teams with a strong “lean” on Lencioni’s Five Dysfunctions of a Team (if you haven’t read it, READ IT!).

I could summarize some of the talk, or give you chunks of it here in the blog over time, but I think I would prefer to just share it with you in its PPT format. While you’ll miss out on my commentary about some of the items this way, it’s got plenty of resources and ideas that I hope will be valuable for you.

A few weeks ago I got a message from a resident with a scholarly interest in education who, in digging through some of my blog archives, discovered my 2014 post discussing my implementation of a wiki as part of our learning format for our surgical clerkship students. It highlighted a couple of things for me- first, that I never followed up on if it was a successful innovation, and how it might be relevant in today’s medical learning environment. The pandemic forced expansion of online learning for all groups of learners, and though I wasn’t in a teaching role this year I recognize that some of my “out there” ideas were probably ripe for resurrection. I also spent my year enrolled in a graduate program that was entirely on-line and saw both effective and ineffective virtual discussions…and have some new ideas based upon that experience.

In that initial post I acknowledged ways that I had desperately tried to foster asynchronous sharing of learning resources by our students, and that my efforts had been at best marginally successful. Because it was a required part of the grading rubric, participation in the board-style question discussions was somewhat more successful (and did achieve the intended goal of boosting scores on the NBME surgery shelf). However, my intent to use our online learning platform to facilitate social learning was never really achieved.

Recent scholarly work on wikis has complicated findings. While they have “great potential” as a learning tool, the absence of measurable outcomes following their use has remained a challenge. A concern raised by learners around wiki use for interprofessional education was simply that they felt it was valuable but required too much effort; this certainly aligns with the feedback that I received from our students in the surgical clerkship.

Two recent studies have provided more support for the idea of using wikis in medical education, and perhaps give guidance on how they can be most effectively deployed. One study employed “social pedagogy” (I love that term!) for their pharmacology course; by using Bloom’s taxonomy to guide learner activities and self-assessment, their wiki was successful in achieving learner success, as measured quantitatively, and also was able to demonstrate several qualitative benefits (and a generally positive reception by learners). Another recent study examined the effect of a wiki in conjunction with a flipped classroom, which also showed positive response from students, and demonstrated that flipped classroom pedagogy buttressed the use of the wiki.

Knowing what I know now, I absolutely would repeat an experiment with use of wiki-style learning, specifically for surgical learners. I have to admit that I would be more “intentional” about it- what is my goal that I’m trying to achieve for the learners- and I would absolutely have a plan for evaluating the intervention. Also, reinforcing the use of the wiki with existing tools or frameworks appears to be important to supporting learner success. Finally, having clear “ground rules” of community engagement and a rubric to evaluate interactions is absolutely necessary. I don’t know that we’ve got the details of how to deploy wikis in medical education completely ironed out, but I do know that it’s an idea that it’s worth our time as a continued experiment.

Confessing my guilt up-front about two things:

1. It’s been a while since I wrote here. My best excuse (and it’s pretty true) is that the energy I might have spend blogging during the academic year was instead expended upon brief writing assignments for my graduate coursework. If you’re interested in any of my discussion topics from Indigenous Food Systems and/or Federal Indian Law & Policy, I can accommodate you. And with that nod, an acknowledgement that I have every intention to do better about sharing my thoughts with you starting now.
2. Today’s title was intentionally chosen because this concept has captured my attention. No, there will not be gratuitous snake photos to accompany the post. I am not a fan of snakes. I am, however, a fan of the concept of pythonic habitats because they account for a not-uncommon phenomenon I’ve witnessed in academic medicine.

The amazing Dr. Mary Brandt referenced Rev. Larry Kent Graham’s book on moral injury in a recent talk she gave as part of the American College of Surgeons Leadership Summit. I was in the midst of preparing a grand rounds on well-being in surgery, so I promptly ordered the book because I had a sense it had important lessons to share. And, indeed, the link between moral injury and absence of well-being is almost undeniable.

A foundational section of the book discusses what Graham describes as the “four intersecting conditions” that give rise to trauma, with trauma defined to include moral injury. While all of the others- explosive assault, a road wrongly taken, and grievous loss- can seem intuitive, the words “pythonic habitats” made me sit up and notice differently. These “benign, constricted, and dangerous environments” slowly and inexorably “squeeze the life out of us.” He initially discusses relatively obvious pythonic habitats, in which people constantly live on the edge of situations that are a danger to life and health- there’s no single defining event, but instead a series of threats that require ongoing vigilance. Although Graham provided a more complex example of individuals with access to the nuclear triggers or who guide drone warfare, in which they do isolating work with moral consequences then go home to have dinner with their families, when he mentioned “benign normality” of their daily lives I immediately thought about the work that we do in medicine.

Think for a moment about the things that we do as part of our work caring for other human beings; surgeons, I’m particularly looking at us. When is the last time you had an experience caring for a patient that you can discuss quietly with a colleague- out of earshot of non-medical people- but wouldn’t dream of discussing over dinner at home? The reality is that we are witness to or actors in situations all of the time in our work that isolate us and that demand that we compartmentalize our lives. And somewhere along the way we all decide that it’s just business as normal because it’s what we have to do. Here’s a hint: it’s not normal, even though it may be necessary, and that causes moral dissonance for us.

Pythonic habitats struck me because while they are unavoidable in our profession, we generally don’t acknowledge their presence. We become the proverbial frog in the cold water that gets heated up until the water is at a boil, and the only escape tools we learn are those we see in the hidden curriculum; there’s little intention in how we all deal with this unrelenting constriction. Over time, unless we do consciously address it, that constriction takes a toll on our physical and mental health. And, as Dr. Jillian Horton states in her beautiful recent book We are all perfectly fine, “Most doctors look fine, perennially, until the day they don’t. That’s because doctors are excellent at compartmentalizing. We are also compliant and conscientious and rigidly perfectionistic, characteristics that put us at risk for choking to death on our own misery.”

I’m not going to profess to having a perfect solution for dealing with these pythonic habitats, though I am committed to seeking a remedy that will help to keep us whole. My hope is that by naming it- and acknowledging that it’s not normal- that at least gives us the possibility of moving towards recalibration and healing.

“I’m apprenticing myself to hope and learning as much as I can. I’m making space in my mind for the good thoughts, so they can nestle in and sing.” – Maggie Smith, Keep Moving

I suppose I’m doing a bit of bandwagon hopping, though as we’ve moved through the first half of March it’s pretty hard not to reflect on the last time that things felt “before-times” normal. The truth is that we are marking an anniversary right now that most of us didn’t think would need to be an anniversary, and the implications of that anniversary are heartbreaking, frustrating, confusing…and yet it seems irresponsible to ignore some of the good things that have come of Our Pandemic Year. If you entered March, 2020, struggling in your ability to hold “both/and” type mindsets, I suspect this year has expanded this skill set for you.

Let’s start with the assumption that you, like I, didn’t see the duration and severity of the pandemic coming- or at least not from the seat you were in on March 12th, 2020. I was spending this week watching professional meeting dominoes tumble as the Committee on Trauma, then the American Burn Association, then the ACS Leadership & Advocacy Conference were serially cancelled. Elective OR cases quickly became a thing of the past. Medical students were pulled from clinical services. I found myself online ordering masks so I could at least have an au courant fashion accessory (have you SEEN my triple layer fabric dinosaur mask?!?). It was as if life went from 1000 miles per hour to a snail’s pace.

That pace change is arguably what I will remember the most from this year.

Now, I say that recognizing that I had decided to take a sabbatical prior to the pandemic becoming what it ultimately became. I already knew that I would benefit from some unstructured time to be creative, to learn, to reconnect with family (and framily) that had I been failing to center. It had also become clear to me that I needed to make decisions about my professional commitments for the next 10-12 years; my efforts to keep one foot in the world of medical education and the other in the world of burns and critical care was resulting in no balance among any aspects of my life (personal or professional). The one thing that I knew for myself prior to “pandemic” inserting itself into all of our vocabularies was that what I was doing and how I was living wasn’t sustainable in any way. Well, that, and I wasn’t going to keep doing it.

Today isn’t the day for me to wax poetic about the sabbatical experience so I’ll simply say that it’s been everything that I hoped for and needed. I’ll also gloat for a moment and share that the last winter when I got in this many ski days was 2001-2002 (for those keeping score, that was my professional development year during residency). More on all things sabbatical in the future.

As part of processing this pace change, I’ve also spent time considering what I want to take forward with me to the “after-times” as we see glimmers of hope on the horizon. So, what do I hope is durable?

• Weekly, or at least very very regular, virtual happy hour with a dear friend. I think in the last year we’ve missed 4 weekends, which almost makes up for the absence of in-person time (though we have also calculated that it’s “just” a 12 hour drive from Portland to Bozeman and we are both fully vaccinated now).
• Gathering outdoors when the weather is suitable for it anyway. Why weren’t we/I doing more of this?!?
• While I miss the soul nourishment of seeing colleagues from other places, I have loved sleeping in my own bed and learning virtually with professional meetings. Are we really going to go back to those wild academic travel schedules we endured? I’ll be surprised…
• Framily/ COVID bubbles are amazing, and I’ll be keeping mine if/when I re-settle away from Montana. Granted, the core of mine has been my residency “sister”, her husband…and their 5 kids; we’ve simply reunited and built on what we started 20-something years ago. Having them close by has made the Montana portion of the COVID year not just manageable, but downright fun. I do NOT have enough gratitude for these humans, even if one of the 9-year-olds is eternally convinced that he’s taller than I am (he’s not…yet).
• Old fashioned cards and letters. I’ve sent more cards and letters this year than I can count, and I hope they’ve done as much good for the recipients as they did for me to write and send them.
• Honoring mental health. Although the pandemic has been hard on mental health in many ways and for many people, the fact that we have space to acknowledge this seems like such a quantum leap. Y’all, it’s okay to not be okay…and it’s okay to ask for help.
• Sabbaticals. No, really, we need to normalize this. But, again, that’s for another day.

What will you remember most from this year?

And what do you hope doesn’t go away in the after-times?