Don’t be cruel

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

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

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

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





Wasting of time sitting still?

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

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

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

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

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

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

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

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


Reading-Round Up, February 2017 edition

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

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

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

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

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

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

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

Happy reading, all.

I was a stranger and you invited me in

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

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

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

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

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

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

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

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

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




Starting them young

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

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

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

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

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

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


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

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

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

Like this:

Just right 👌

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

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

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

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

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

Gratitude: It’s good for your team AND it’s good for you

Let’s start with a question.

How did you feel the last time someone provided you with a sincere thank you or kudos for something you did?

If I’m a good judge of human nature , I suspect it made you feel pretty good.  Perhaps your body generated a nice surge of dopamine. I would also suspect that it generated some good will towards the person who said the nice thing about you. You felt seen, and valued- two of the things that we know are so important to developing a sense of empowerment and belonging. And, of course, empowerment and belonging result in loyalty.

Gratitude is an important, and sometimes underestimated, leadership skill. Let me be clear about one thing before you decide to just go around saying, “Thank you” to everyone in sight.  That won’t get it.  Appreciation needs to be personalized, and if you can be creative in how you show appreciation, all the better. Personally, one of the best acknowledgements I’ve received recently was from a friend and sorority sister whom I work closely with. Last weekend I couldn’t run my planned half marathon because of illness.  And the text I got from her….well, it knocked my socks off.  It was a well-timed reminder that I can do hard things, I just couldn’t do them last Sunday morning.  And that’s okay.  She is someone with an incredible gift of gratitude and appreciation, and it makes her FUN to work on big projects with.  It also makes her a wonderful friend.

Appreciative Leadership has a summary table of 7 reasons to be generous with appreciation. Taken from Table 6-1  in the book, the list is as follows:

  1. Recognition lets people know they are on the right track
  2. Appreciation communicates and reinforces your values
  3. Compliments foster a positive emotional environment
  4. Gratitude is a verbal immune boost; it is good for your health (we’ll come back to this one shortly)
  5. Praise is good for the health of those you honor
  6. Acknowledgement creates a sense of safety (SO important in teaching and learning environments!)
  7. Gratitude encourages risk-taking and experimentation

The reality is that a culture of gratitude helps to promote high performance by teams.

Here’s the thing: While appreciation is the right thing to do for your team, it’s also the right thing to do for yourself. Many individual-level benefits of practicing gratitude are becoming increasingly clear: it improves both physical and psychological health, enhances empathy, improves sleep, enhances resiliency…the list goes on. If you look at that list closely and if you follow the literature on burnout, you immediately recognize that gratitude might just be one of the cornerstones in combating burnout.  Again, from personal experience I know that on days when I am feeling particularly frustrated and as if I’m tilting at windmills, the best thing I can do is pause and think about something I’m grateful for.  On bad days, it might be that I’m only on call for 4 more hours.  On less bad days, the list is typically much more robust.

Weekend homework, friends. Before you go to bed tonight, tomorrow, and Sunday night, write down (yes, write it down with pen or pencil on paper- it does imprint better that way!) three things you are grateful for.  I’m helping you to kickstart your personal gratitude practice.  Next week see if you can extend sincere appreciation to people you work with.  I’m willing to bet you’ll make someone’s day and make them want to do an even better job the next time you work on something together.

You find what you’re looking for

I can’t help but think there’s a word for the phenomenon when you get interested in a topic, start learning about it, then start finding things everywhere that enhance your learning process.  Okay, I Googled it.  It’s the Baader-Meinhof phenomenon.

In my case, I’m currently participating in an on-line seminar called “Art of Activism: Hard Conversations- Intro to Racism.”  This week’s lesson centers on structural/ institutional racism, and I am absolutely experiencing the Baader-Meinhof phenomenon.

The lessons in the seminar have been EYE-OPENING, I assure you.  And yes, that word merits all caps.  I consider myself to be relatively enlightened about the ways in which our social and legal structures reinforce racial inequality and serve as barriers to full social justice. And in spite of feeling like my knowledge in these areas is above average (recognizing that they are not experiential, of course), every day I am reading something or watching a video that challenges me. Some of them break my heart, some of them leave me angry, some leave me frustrated, and they all leave me realizing that we have so very much more to do to build the world that I want to believe we have and a world that we all deserve.

If you want to enhance your own understanding of structural racism, this is a great reading.

If you want to better understand the history of structural racism, here’s a brief video (with a link to a longer video, if you wish):

What do you know about disparities in the criminal justice system? Education systems? The financial system? Health care? How can you learn more about these things?

I’ll summarize for you: The disparities are huge, they are institutionalized, and they are real. Every single time that one of us denies that part of the issue is systemic and we blame individuals, we’re continuing as part of the problem rather than the solution. Equip yourself with facts, and listen deeply to the stories of those with first-hand experiences of discrimination.

I don’t know how many of you are familiar with the Angola 3, one of whom (Albert Woodfox) was kept in solitary confinement for over 40 years in Louisiana’s penal system. This article in this week’s New Yorker introduces you to Albert Woodfox and his story.  I’ll comment that he is a truly remarkable human.  Reading about him helped me to develop a deeper empathy for the Black Lives Matter movement than I’ve previously been able to muster.  And, as I lead with, this was something I would have read less deeply were I not engaged in this seminar.

For my readers who are people of color and who are LGBTQ+: I want to know how those of us who are white and/or cis can be the most helpful in fostering change. I need to understand what that change is not from my perceptions but from your lived experiences. I don’t know and can’t know what it’s like to wake up every day as a Latina, or a black man, or someone who is gender binary. And without your experience, I don’t know how to use the influence that I have to insure that you are included as you deserve to be.

If you are a male reader, I hope that you’ll also include women’s experience as something you seek to hear, understand, and improve. I’m happy to discuss both explicit and implicit gender discrimination with anyone who is willing to hear.

One last resource before I issue a challenge to you.  This Catalyst document has some excellent tips for engaging in conversations about gender, race, and ethnicity in the workplace (again, something a resource I came across serendipitously today; thanks, Twitter). I hope you’ll find ways to use it.

I’ll close with a challenge to each of you: Can you think about what is good or important about discussing inequality? What is hard about it? And how can you manage the hard parts to enjoy the good/ important aspects?

Let’s do this together, friends.  It’s going to require each one of us to find solutions, to reach out, to make a difference.





Resolved: We need to be able to have dialogues and debates

With my recent post encouraging us to seek the Other, it seems like an important time to dive into debate and dialogue as tools we use in communication. One of these is, by definition, a better way to deeply listen to someone with a different viewpoint.

Quick question for you: What comes to mind with dialogue?

I personally tend to think of open mindedness, seeking common ground, and a willingness to change in belief or action based upon what one hears.  I see dialogue as not being zero-sum.

What about debate?

It feels more confrontational, critical, difference-based, focused on winning and losing.  Debate is usually VERY zero-sum.

We know that one of these things is the place we should go when we’re dealing with people and ideas who are different from us.  But dialogue requires a lot of work. And energy. And attention.

Is debate inherently “bad”? Definitely not, and it can be used very effectively.  If you’ve been given the opportunity to argue a side in a pro/con that you don’t agree with, you know how much you learned (and that you possibly changed your mind afterwards!)

Fostering dialogue within a group, however, improves inclusion.  It helps us make better collective decisions. In the most dramatic situations, it helps foster peace.

Clearly this is the extreme, idealized version of deep listening.

However, if I think about the times when I have sincerely tried to listen like Thay describes, I have learned so much about myself, about others, about the world.

From a more business-based perspective, it is possible to foster deep dialogue among team members using a collection of tools.

And if you’re wondering, yes, one of my 2017 goals is to work on my deep listening.  I would challenge you to join me. I would also challenge you to help keep me accountable on the days when I’m struggling.




Not the usual suspects

As I mentioned in this week’s reading round-up, I am completely enamored right now with the book Appreciative Leadership. I recognize that some view my tendency to skew positive as a leader as a shortcoming, and what I most value about this book is that it takes that it’s giving me great ideas to take that positive skew and convert it into positive power.

Last week I was reading the chapter entitled “The Genius of Inclusion,” which has sections on improbable pairs and and a section encouraging us to reach out to the “Other” as an act of inclusion. The take-home message from these sections centers around the importance of truly listening to someone who is different from us; it helps us learn what we have in common with people (which may not be at all obvious on first pass) and it also helps us to build trust and foster respect. The authors encourage the fostering of improbable pairs within our teams, in which team members choose a partner whom they believe to be greatly different from them and then do a 20-30 minute appreciative interview.

Let’s extend that idea of the improbable pair further out of our comfort zone since used within a team there’s at least one thing we have in common with the other person.  What about the Other, as the authors refer to it? We all have an Other- a person or group of people whom we like or don’t trust.  American politics this year has proven just how relevant this idea of Other has become, particularly in the face of a lack of willingness to listen to ANY opposing viewpoints (which, for the record, is behavior I’ve seen at both ends of the political spectrum).

So, an exercise for you this week, friends, that I’ll admit I straight up stole about half of from the book.

  • Who are your Others? How did you learn to see them this way?  We all have them, and if you say you don’t, you’re not being honest with yourself or others.
  • What might you be missing out on by excluding them?
  • How can you reach out to an Other to learn about them? I bet you know at least one whom you can have a conversation with, and whom you might even be able to build a bridge with.  Go do that.

I know this isn’t an easy exercise, and that in some ways it’s downright scary because it challenges a core belief about your Other. But what do you have to lose? And think of what all you have to gain if you discover that while your Other is quite different from you and you have common ground with them.  You might just change your life and theirs.