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.

 

 

 

 

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.

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.)

 

 

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?

 

Hangry in the Hospital

Admit it- we’ve all been there.

You’ve got all of 5 minutes to get lunch before the next thing on your schedule and your pager goes off about something that needs your attention urgently.

You haven’t peed in 10 hours and a staff member who needs something for a patient starts to follow you into the bathroom (even though the patient need is not truly something urgent).

You’ve been taking care of everyone but you for the last 29 hours, a patient decompensates, and you’ve got to handle it because no one else is available.

You get paged at 2 am for berry blast tums because the patient doesn’t like the usual flavor (yes, this actually happened, though not to me).

The truth is that our healthcare system isn’t well designed for us to partake in self care.  While I know it most intimately from the ICU physician/ surgeon side, I see it exacting similar tolls on nursing staff, aides, PTs and OTs, pharmacists…really anyone who is involved in the nitty gritty of patient care. We get hungry (or hangry), we get tired, we get pulled in at least 6000 directions, all because we’re trying to do our best to take care of the patients and their families.

On Tuesday my team and I attended the March installment of Schwartz Rounds at the University of Utah, and the title of the session was the same as the title of this blog post.  We got to hear from people who work in the healthcare environment in very different roles and get their perspective on how challenging our jobs as caregivers make it to take care of ourselves, and there was a great discussion about the role that culture plays in that.  If I ask the staff to try to let me catch a 20 minute catnap while it’s slow, am I perceived as weak? If I call my supervisor to let them know I’m currently overwhelmed with patient demands, does that make me an incompetent resident? Putting those potential opportunities for shame into context was, quite honestly, eye opening.  Our culture in healthcare mandates that as care providers we all run fast, leap high, and do all of the right things for everyone with a smile on our faces at all times.  Reality mandates this simply can’t happen because we’re all human.

We all have basic things that we can try to do to help ourselves just a bit.  I have a cache of healthy snacks at all times and I have two water bottles in the hospital (one in my office, one on the ICU).  One of my “treat” tricks is that I have a stash of teas that I can brew up for me, which is an inherently stress-reducing activity, and that I am willing to share with team members as a boost. I’ve been doing this more recently and I’m starting to wonder if good loose-leaf tea simply has magical calming properties, even when it’s got caffeine.

One of the things that struck me the most during the Schwartz Rounds discussion was the role that leaders and teammates can play in creating a culture where we’re allowed to be human, where we somehow manage to get something nutritious to eat, where we can actually function at our best because we’re taking care of ourselves in the little ways that can add up when we’re stressed and tired and hungry.  I realized as I was listening to a few horror stories that we are so fortunate in our unit to have a culture where we try very hard to take care of one another, be that by grabbing a coffee for someone’s morning fix, running to get someone lunch who is swamped, or simply having that willingness to step up and lend a hand when it’s crazy so that no one person has to shoulder too great of a burden.

Here’s my challenge for each of us this coming week: Think about the things that you wish someone would do for you when you’re hangry in the hospital. Then offer to do one (or more) of those things for someone on your team. You never know when you’ll need the same favor, and I can assure you they’ll be grateful for the kindness.

 

 

 

Meanness about surgeons

This past weekend a Major Medical Blog (which I refuse to link to because this is the 2nd time they have published an incredibly inflammatory piece about surgeons and surgeon behavior that was anonymous and likely not-fully-founded) published a piece that was described as advice for parents of surgeons.  It essentially consisted of advice to be downright mean, entirely lacking in compassion, and the type of person that no one actually aspires to be unless they are a sociopath if you want your child to grow up to be a surgeon.

While I did not like the post, I was delighted by the response to many of my friends and colleagues to it. Essentially, the theme was that the behavior described is not condoned in American surgery in this day and age, and that in most places it isn’t even tolerated. I felt buoyed by the fact that my in-person and on-line community is a place where we truly believe in goodness, and where we don’t buy into the now mostly historical legend of Surgeon Horriblis.

And yet…it seems like it’s a monthly event for us to have to go on the defensive about our profession and the fact that we really don’t eat our young, we don’t yell all of the time, and we don’t want to have peers who do those things. Someone somewhere is publishing something about what terrible people surgeons are and those of us who are the opposite of terrible have to stop, step in and say, “No. That’s not who I am, and that’s not who my people are.”

I’m tired of it.  I’m tired of people meanly accusing us of being mean. If we hit back, they get to say, “See!  You’re mean and terrible!” or alternatively, “Okay, maybe it’s not all surgeons, just most of the ones I have encountered.”  If we stay silent, people assume they are speaking truth and we’re complicit in propagating the terrible PR for our surgical family.  What’s a nice surgeon to do?

Well, for one, we keep being nice.  We kill them with kindness. We keep telling them that’s not our experience, and that we know plenty of folks who are amazing role models. I often tell people that while I started medical school with the idea that surgeons were scary, I fortunately had several surgeons successfully convince me otherwise during my 3rd year.  Were it not for the goodness and the humanity of Sam Snyder and Danny Custer at Scott & White, I openly admit I would likely be a pediatric intensivist today. Fortunately I was open to having my view changed- and change it they did.  I still have infinite respect for these two men and I’m grateful that they showed me that someone can be an excellent surgeon and an excellent human.  I know I don’t get it right every moment of every day, but I try pretty hard on both fronts.

In my professional role in our Department, I’m perpetually focused on bringing myself and those around me to a higher level of effectiveness through successfully communicating and building teams (and yes, that means playing nicely in the sandbox with others). So, surgeon friends, perhaps we need a new social media hashtag so that we can talk about #surghumanity? Much like a few months ago when I wanted to catch Millennials doing great things (which is only hard because it happens all of the time), maybe we need to make show the world surgeons being…human beings.  Because we are, and quite frankly I’m exhausted by all of this nonsense telling me that my people are insufferable.  I’m not, and neither is my surgical community.

Stop explaining, stop talking.

One of the places in medical education where I am well-convinced that we are still failing our trainees is teaching them how to have hard conversations. It’s simply not a part of the curriculum, so they rely on role modeling; as we know, that role modeling is as likely to be negative as it is to be positive. We also know that our students lose empathy over the course of their clinical training, and that the loss of empathy contributes to physician burnout and all of the negative repercussions associated with burnout.  And, of course, there’s the simple issue of the fact that no one actually enjoys delivering bad news and having hard conversations with patients and families.  It’s emotionally easier to not have the talk, or to deliver platitudes, or even to provide that little bit of false hope they can grasp on to so you don’t have to be the bad guy or bad girl.

The erosion of empathy has been a long interest of mine for both personal and systemic reasons.  Personally, I know I suffered from a tremendous (and in hindsight somewhat embarrassing) loss of empathy during the 100+hour workweeks of my residency, and that paucity of empathy applied to pretty much everyone, not just patients and families. I’m not saying I do it right 100% of the time now, but I’ve at least developed a tool set so that I’m usually aware if I’m entering an empathy-loss danger zone. And, of course, I’m interested at a systemic level because of the impact that empathy loss has on professionalism and our ability to work effectively as a team member or leader.

In order to remind everyone about the difference between empathy (healthy, connecting) and sympathy (not healthy, disconnecting), here’s a brief video lesson:

 

So, empathy is feeling with people. Courses are being developed to help us respond to patients and families in a more empathetic manner, and those courses often prescribe similar interventions:

  • Give the patient/ family, not the computer, your undivided attention.
  • Sit down!
  • Avoid medical jargon. Remember that part of medical school was learning that 2nd language of medicine- how would you explain this to your Aunt Velma, the 3rd grade teacher?
  • How you say it may matter as much as what you say.
  • If the patient is telling you about their feelings, don’t respond to them with facts. Doing so implies that you’re not hearing them.
  • When you’re scheduling a hard conversation, allow more time than you expect it to require.  This is not a time to be in a hurry.
  • Stop explaining. Stop talking.  Sit in the silence, no matter how uncomfortable it makes you. I love the quote that “doctors are explainaholics” (because we are).  Again, stop talking. It’s amazing what you can learn when you give people time and space to share with you.

As an additional aside, I would add that fostering these communication skills is also helpful for having hard conversations as a leader. While some of the details are different (you can probably use medical jargon with a junior colleague if it’s needed), all of the other rules absolutely apply.

Empathy is hard. It requires work, and it’s something we have to practice routinely in order to become good at it- much like being a surgeon, being a musician, or being a person. We need to recognize when we’re offering up unhelpful silver linings (or sandwiches) rather than genuinely connecting.  It’s scary, but it’s also worth it for our patients, their families, our colleagues, and ourselves.