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.

August reading round-up

To quote the Talking Heads, “How did I get here?”  Seriously, y’all, where is the year going?

Anyway, to the business at hand…this month’s reading round-up.

If you’re interested in the intersection of gender and academic medicine (which is something that’s just a bit of an interest for me…), check out August’s Academic Medicine.  And yes, I do mean essentially the whole publication.

I was touched by this essay in JAMA Pediatrics. Much like the author, in my line of work it’s near impossible to not form an attachment to patients and their families because of how long we’re together and the difficulties of the work.  I will also confess that, like the author, my ongoing personal ties to some of my patients and their families is precisely what prevents burnout and discouragement during the hard times.  We are part of one anothers’ stories.  Period.

Another piece on women, this one about women in surgery, and it is the Julie Freischlag’s Jonasson lecture she gave last year. Bouncing up is a great thing to remember to do in life, not just in academic surgery.

Concurrent surgery is a hot topic still; this Viewpoint provides an important perspective on informed consent.  I’m proud that the U of Utah seems to be ahead of the curve in this area.

Pleasure reading?  I’m just starting Rachel Cush’s Outline for our August book group.  The discussion around last month’s read, The Secret Scripture, was phenomenal!

 

Tomorrow is another day…

Why do today what you can put off until tomorrow?

Why do today what you can put off until tomorrow?

It’s an activity that looks different for each of us- and it only applies to self-directed responsibilities.

It’s been identified as a basic human impulse, and one that we know is inherently irrational.

We do a remarkable job ignoring its consequences.

When I was in college and needed to write papers, it usually resulted in mass quantities of baked goods or a large roux pot of étoufée.

Now?  Well, now it occasionally (thought not always) looks like a blog post.

We are all, each of us, procrastinators by nature. The reality of a future benefit of whatever action or task we are putting off is far less significant to us in a given moment than the potential immediate gratification of something else we could do right now- particularly if the delayed action or task isn’t something we actually enjoy.  Those things in the future tend to be pretty abstract as well- and they are certainly more abstract than something sitting right in front of us.

Sometimes procrastination can be used to our advantage; poet David Whyte appropriately mentions that it may provide time for ripening of ideas. He also counsels that we should use procrastination as an opportunity to careful sit with why we’re delaying the action or task in question, reminding us that sometimes the time that it gives us provides us interaction with something much bigger than ourselves.  I’ve felt this more than once when I’ve given myself a bit more time than I might have liked while working on a manuscript, only to find that when I finally do get my backside into the chair that it magically ends up “just right.”

However…we all know that procrastination isn’t entirely to our benefit.  We know we need to keep up with our documentation, but sometimes the Epic inbox is just so…overwhelming.  We know we should respond to a couple of emails from colleagues, but we’re going to say “no” to something they’re asking us to do and we don’t want to disappoint them. The phrase I’ve come to use around the types of tasks we tend to put off even though they are necessary?  We have to eat our broccoli (or some other vegetable that may not be your personal favorite).

This week the HBR website had some tips and tricks on how to beat procrastination for those times when it’s not working in our favor. I have a favorite from each group- in the first group, it’s thinking about how great you feel when that task is completed.  Admit it, it’s nice to have your Epic in-box empty. For the second group, it’s figuring out the first step that you need to take to get started; this concept works best for more abstract, bigger things (like starting a manuscript).

So, what are you going to get done today that you’ve been putting off?

 

 

 

Words, words, mere words

This link describing the difference in language in performance reviews of men and women came across my Facebook and Twitter feeds.  To summarize the HBR piece it draws from in one sentence, men are more likely to get specific information about what they are doing well and what they need to do to get to the next level than are women.

Men get feedback on technical aspects of their performance. Women get feedback on their communication style (when is the last time you heard of a man being described as “aggressive” in an evaluation?). Men get constructive suggestions.  Women get constructive suggestions and are counseled in effect to sit still and look pretty. Men are acknowledged for their individual results.  Women are described for their team accomplishments. Men are expected to be independent and self-confident.  Women are criticized if they aren’t collaborative and supportive.

The real issue with the implicit bias that appears to pervade evaluation in so many areas of business and tech is the impact it has on women’s professional development. Although little work has been done to date, I suspect that the same phenomena are at work for medical students, residents, and women in academic medicine.

And, of course, since I always try to bring solutions for the problems I share, I’m particularly fond of solutions modeled on those recommended in the HBR article. For those of us in roles of evaluating our learners and our peers, how can we best do this to mitigate the unconscious bias?

  • Use specific criteria (or anchors) to evaluate individuals. What does competence look like for a specific skill or activity? What does mastery look like?
  • Set three measurable outcomes to review for each individual.  These may vary from one to another (no two individuals are alike); the key is that they should be measurable.
  • Relate feedback to goals or outcomes. Instead of saying, “Great job during that OR case!” perhaps we should mention to the resident, “The time you spent getting good exposure of the trachea made the actual placement of the tracheostomy safer for the patient and technically easier for you.” Or instead of saying, “The whole room thought you were panicky during that trauma activation on a patient who was clinically stable,” we could say, “We should work together on you maintaining command of the room during low-level trauma activations so that you can do the same when we have unstable patients. When you seem anxious, the team picks up on that and it impacts their care of the patient.”
  • Written reviews should all be of similar length- which also means similar level of detail.

I know that I’m discussing these issues largely in broad strokes. I’m also not finger-pointing at anyone in particular, especially because it appears that women bosses and men bosses are equally guilty in the business world. I’m also curious to look at evaluations I’ve written over the last couple of years on students and residents to see if I’m guilty. If I manage to pause and adapt a comment I might make tomorrow morning during our residency review meeting, it’s a victory for me and for that learner.

Most importantly, I want to put this in front of you, my readers, because the best way to beat unconscious bias is to realize that it exists.

 

Staving off the demons

This review of burnout in surgeons was published online in JAMASurgery last week, as was this Viewpoint on resilience and its relationship to burnout.

Of course, the root causes of burnout in medicine and surgery are protean. Specialty, gender, workhours, EMRs (yes, the EMR is being blamed now), basically anything that can contribute to job dissatisfaction regardless of profession are possible catalysts for burnout.

I openly admit that I don’t spend much time discussing burnout. It’s not that I don’t care when my colleagues are suffering; I do care deeply about them and their distress. For me, it’s that discussions of burnout and “what’s wrong with surgery/ medicine today” tend to be problem focused.  While people have generated all sorts of inquiry around risk factors for burnout and descriptions of its impact, resilience and recovery are woefully neglected. And yes, our systems should try to help mitigate controllable things that are clearly risks…but there’s so much more to the picture than the systems, and those other things get complicated.

I’m also not saying I never have a sense of being burned out. There are weeks when I fear that I’m generally in over my head, when I’m exhausted, and when I feel like I have very little control over anything. Had you asked me to fill out a Maslach Burnout Inventory at 11 pm last Friday night, I’m reasonably certain that I would glared at you and ended up with a score very consistent with burnout. In contrast, had you asked me to complete one at 11 am on Saturday (after 6 hours of uninterrupted sleep on Friday night and an 8 mile run with my running “tribe”), it probably wouldn’t have looked nearly so dismal even though I was back in the trenches of patient care and was having a busy day.

Here’s the thing: I could have skipped my Saturday run and slept more, and I’m certain some would say I should have done just that. However, physical activity that is a challenge is both grounding and restorative; thus my love of running and the basis for my nine half marathons in the last year. And while some days it really is about the running to process and running to manage on energy, Saturday was a day when it was running for connection. I knew that the best thing (again, for me) to get my head back where I wanted it, to feel like I had just a bit of control over my crazy life, and to enjoy simply being in the moment was to get up early and meet my running group.

8 miles later...

8 miles later…

I’m going to tell you that your mileage may vary- your “thing” doesn’t have to be running. But what your “thing” does need to include is connection. Saturday morning I needed time with these friends- friends who cheerlead, who love unconditionally, who are incredibly funny, and none of whom are in medicine. I didn’t need for them to understand what my week had been like.  I just needed to be with them for a while doing something that we all love.  Brené Brown is right– we are all hard wired for connection.

Find your tribe. Love them hard. Most importantly, spend all the time with them that you can.  What if it really is that simple?

Celebrating, tempered with a few tears

I lost a friend this week.

That’s the selfish statement, and it’s the only moment I’ll take to be selfish and indulge in it being about me.

While I lost a friend, and someone whom I was so fortunate to get to work with on policy and advocacy with the American College of Surgeons, this loss isn’t mine, and I know it’s felt more deeply by some who were closer to him.  Chad was a role model, someone who I would easily say I want to be “when I grow up” (even though I think he would be displeased with me referring to him as being a grown up).

Chad’s obituary says little to help those who didn’t know him understand who he really was; you get an inkling from the picture with his fabulous, mischievous smile and more hints from the descriptions of some of the accolades he received.

When I started on the Surgeons PAC Board, it was an intimidating place.  I was the youngest surgeon in the room who wasn’t there as a representative of the residents or the young surgeons, and I was the only woman surgeon in the room. Chad was an immediate friend- someone who made it clear that my being there was important to the group and to him personally.  We bonded over policy wonk things, and we bonded even more over our devotion to our rescue animals.

Here’s the most important thing about Chad, and why I said I was celebrating as I write: he would not want it any other way. When I remember Chad, it’s almost entirely about his kindness, his generosity, his belief that we each really can make the world around us better and that it’s not an overwhelming task.  Chad was smart, he was funny, he was talented, and he cared deeply.

My wish is that each of us today will dig deeply to be a little kinder, to be a little more thoughtful, even in moments when it’s not easy to do so (or particularly in the moments when it’s not easy to do so).  I’m also remembering this week the importance of making that call, finding the time for that friend.  You just don’t know when it will be the last time you get to be with them.

 

(N.B. I drafted this a couple of days ago, before Philando Castile was shot and killed and before last night’s unimaginable events in Dallas. I thought about keeping the blog dark today because of those events, mostly because I simply have no adequate response to what’s going wrong in America right now. Then I decided that I was going to post remembering Chad because he was so filled with kindness and goodness, and that is EXACTLY what we need more of right now.)

 

 

July reading round-up

Here’s hoping that the long holiday weekend wasn’t particularly cruel to any of you- and here’s some summer reading that has caught my eye.

This paper questioning who will be able to do an open chole in 2025 was one of the highlights of the 2015 Western Surgical Association meeting.  It generated some interesting discussions, both real-time and in the ACS Communities.

Since I’m not “really” a general surgeon (I haven’t operated in the belly in several years!), I’ve followed the discussions around early feeding with great interest and no great investment. This meta-analysis of early oral feeding supports this practice- and perhaps shows a benefit in terms of less pneumonia.  Use the gut, people.  Use the gut.

I’ve long believed that leadership training is beneficial; about 8 years ago we piloted a leadership elective for our residents, and I now wish we had done more with it. This study uses qualitative data from the University of Michigan to describe the benefits of leadership training for faculty. It’s great food for thought.

Last month I found myself explaining to a patient’s wife that delirium is one of the greatest challenges that we face in the care of the ICU patient. This month’s Critical Care Medicine has a great overview of the current challenges we face in this area.

And finally, if you want some literary fiction summer reading, I’m in the thick of Sebastian Barry’s The Secret Scripture.  It’s a fantastic, and intriguing, story.  I suspect our book group discussion will be exceptional.