What if it’s not our fault?

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

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

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

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

On to Twitter conversation #2:

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

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

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

What if it’s really not our fault?

Why teach?

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

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

“Why teach?”

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

But why?

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

Why teach?

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

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

So, what’s your story? Why teach?

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?

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.)

 

 

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?

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.

 

The Buddha Walks into the OR, Part 1: Generosity

Don’t shy away from today’s message- my intention is not to tell you that you need to give all of your material goods and money away.  I’m undoubtedly a big believer in philanthropic giving, but that’s a conversation for another day.

Over the last couple of years I’ve done a fair amount of reading of Buddhist philosophy. If you’re looking for modern distillations that are easier to start with, I would recommend almost anything by Susan Piver (including joining her Open Heart Project!), and I’m admittedly a fangirl of Lodro Rinzler; his The Buddha Walks into the Bar and The Buddha Walks into the Office are admittedly the inspiration for this series, the Buddha Walks into the OR.

Within Buddhism there are the 6 Paramitas, or transcendent actions; the Paramitas assume that we wish to live in a good world, and they are tools by which we can help make that happen. The first paramita is generosity (see, now it’s all coming together!); this one was also a relatively easy place for me to start because it has synchronously appeared both in my self-directed Buddhism homework and in my favorite recent self-improvement read, Brené Brown’s Rising Strong. I took that as a sign that it was time for me to start the Buddha Walks into the OR series that I’ve contemplated for the last 18 months.

Generosity, from the standpoint of the paramita, allows us to acknowledge and share our riches in terms of heart, intellect, and experience. Generosity may consist of three different types of giving: material things, fearlessness (loving protection), and wisdom (Dharma). Importantly, giving any of these three things requires that we give freely, with no expectations in return.

No expectations in return provides a perfect segue into generosity’s appearance in Rising StrongRising Strong includes a practice that is simplified as living BIG as a way to maintain our resilience- with BIG as an acronym for Boundaries- Integrity- and…yes, Generosity. In this instance, generosity digs into our relationships with others, and our assumptions that we make around their behaviors.  Specifically, I challenge you to ask yourself this question:

In general, do you believe that people are doing the best that they can?

For those who believe that people are doing the best that they can, you’re offering generosity in your assumptions about people when they make mistakes.  Yes, this assumption still allows (even requires) that we have boundaries, but think about the impact of believing that in general people are doing the best that they can.  Think about the impact of believing the opposite, which Brené refers to as thinking everyone is “scofflaws and sewer rats.”  Believing that people are doing the best that they can requires that we have no expectations in return, and when we practice this, we’re being generous with our wisdom.

And, honestly, it makes all of interactions with the world significantly simpler…

I’m biased here, I’ll admit.  I am someone who believes that in general people are doing the best that they can. In general, I’m doing the best that I can, and I am all to aware that means that there’s lots of imperfection going on here- I do not get it all right every day. But I know my own motivations and I know I’m trying my best; I have also learned that in order to allow myself the space to mess up every once in awhile, I have to offer that same grace to others. We’re human.  We’re fallible. And as long as we’re all doing our best (and I do believe in general we are), there is hope.

 

 

 

 

Maybe we’re not so grand?

Wednesday during the academic year always gives me the opportunity to consider grand rounds- the history, the why, the how could we be doing this better (since we all know that’s one of my favorite questions about almost everything). Today and last Wednesday served as no exception; the prior Wednesday was a break from my incessant questioning, mostly because I was away at Surgery Education Week.

Historically, grand rounds were Socratic in nature, and focused around patient presentations (usually by a junior team member) to more senior faculty.  Often the patient was present, and the presentations were oriented around problem-solving of the cases.  Attendance at grand rounds was expected as part of one’s civic duty in academia and the interactive nature fostered engagement through active learning.

Fast forward to the present- and I’ll open with a confession that I can be complicit in any/ all of these on a given day. Grand Rounds is typically a Power Point (or Prezi, for the more hip) based lecture, hopefully with a few minutes left for questions at the end. Minimal interaction occurs, and the audience engagement often reflects the paucity of direct interaction. Email gets answered, EMR charting gets caught up. Even those who are engaged and attentive are likely to retain no more than 5% of the information provided. The modern model allows people to share from a place of expertise, and for those in the audience it’s typically a fine exhibition of passive learning.

A side effect of the failure of engagement in modern grand rounds is a lack of attendance; if people’s learning needs aren’t being met, they simply vote with their feet and stop coming.  Multiple sources have bemoaned decreased attendance at grand rounds in particular, and educational conferences in general, by faculty members.  Sometimes those absences are unavoidable and are driven acutely by patient needs. Often they are simply a reflection of perceived relevance of the day’s topic, with citizenship “obligations” being inadequate to overcome the pull to take care of the myriad other things on the to-do list during that sheltered hour.

Grand Rounds in some form is likely a tradition worth maintaining, both for the citizenship/ networking benefits, as well as for educational benefits when it’s done well.  The question becomes how do we resuscitate grand rounds before it’s too late? Better coffee?  Bigger controversies? More interaction?

I’m not sure I have a single perfect answer, though I hope to open a dialogue on how we can best identify and meet the needs of our learners.  My suspicion is that it won’t involve a long-term relationship with the lecture format, and it might even entail a return to old traditions with entirely interactive, case-based sessions. Or it might be something entirely different and entirely unexpected- something revolutionary, perhaps?

If you were designing an effective grand rounds for your Department of Surgery, what would it look like?

 

Time’s up!

Meetings.

The beast that is a necessary part of what we do when we work in teams and groups.

An activity that can either energize us and focus our efforts or drain us and lead us to disengage.

I love a meeting that is focused, that is well run, and that lets everyone at the table have an opportunity to weigh in.  I particularly love it when we’re able to “wrap up” with next steps that include accountability for team members.  Putting those items into meeting notes then following up on commitments are how we become more effective.

I loathe a meeting that meanders, that belabors points, that allows those who talk a lot to monopolize the group’s time, censoring the wisdom of those who don’t always speak up first.  Good ideas don’t necessarily get a platform, and those holding those ideas may end up not feeling valued.  Again, disengagement is where good organizations go to die.

I’ve recently been experimenting with a couple of new spins on meetings.  One is the idea of not scheduling them for the Outlook-mandated hour; most of my meetings get scheduled for 45 minutes.  This is conscious because (1) very few things actually need a full hour and (2) it gives me travel time/ recovery time/ task switching time in between.  I’m particularly possessive of the buffer when the prior or following meetings are ones that I anticipate to be challenging or complex. Some have advocated for 30 minute meetings, a practice I haven’t yet quite adopted. Perhaps that’s next.

The other experiment is putting a time stamp/ shot clock onto meeting agendas that are tailored to how long discussions should optimally take. While this forces an adjustment for groups that haven’t worked with them before, they definitely do adapt over time…and it helps keep the meetings on-target and on time.  Two things are key to making the shot clock work.  First, have a timekeeper who keeps everyone honest and lets you know where you are versus the allotted time as it approaches.  Second, have a “parking lot” for ideas that come up and don’t fit within the boundaries of the current discussion.  During the meeting wrap-up portion, make sure to generate a follow-up plan for things put into the parking lot.

Happy time-effective meetings to you!