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.

 

 

 

 

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.

 

 

 

 

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.

We’re all a little green

“How on Earth did HE get that promotion?”

“I really hope they get some bizarre parasitic disease and dysentery during their trip to Peru.”

“What does she have that I don’t?”

“How did they afford that house?  They must be house poor!”

“But I wanted that award!!!” (said while stomping feet and whining, in best 3-year-old fashion)

Admit it: If you haven’t thought one of these things word-for-word, you’ve probably thought something similar. Something happens, something big and great, in the life of someone we know, and we end up ruminating about their good fortune and our lack of the same.

Envy is real. Envy is invisible. Envy is dangerous.  Envy is a sin in every major religion, and it’s definitely not a fun sin (even schadenfreude loses its luster). It’s divisive, even to the point of being toxic.

And in spite of these things, envy can help us to grow.

I know…I just told you that an emotion that is often a “dirty little secret” may not be so bad after all.  Envy helps us gain clarity on things that are important to us, things that we really want for ourselves.  We aren’t going to have envy about something that we don’t actually want.

Envy really comes out of a core belief and a basic behavior.  The core belief is what many refer to as a “scarcity mindset.”  We envy what others get, or we want things they have, because we believe that there’s not enough for us if they get theirs. In reality, that idea simply isn’t true about many things, and we all likely know that. If we let go of this concept that the car/ job/ dog/ house that the other person got is the only car/ job/ dog/ house that can be right for us (we might even find one that’s better!), that’s a giant step away from envy.  The basic behavior that drives envy?  Comparison.  Theodore Roosevelt wisely said, “Comparison is the thief of joy.”  He was right, you know.

So how do we escape the morass of jealousy and keep it from damaging our relationships, both at work and at home?

Envy is a natural, normal part of our human experience.  You should not,  allow the green-eyed monster to harm your friendships, and you certainly shouldn’t let it steal your joy- no matter how harmless it seems.

IMG_1673

(Gratuitous photo of Belle!, the green-eyed naughty and lovable cat, who is in truth a great source of joy.)

The importance of being empathetic

Empathy (and its manifestation in effective communication) has been described as an essential capacity of physicians, impacting doctor-patient communication, patient engagement in their care, and the effective care of patients as a whole. We know that empathy is essential to maintaining physician emotional and mental well-being, including avoidance of burn-out, depression, and suicide.

And, of course, one of the things that we know is that empathy among medical students declines during the third year of medical school. In the traditional curriculum, that’s the year that students start to take care of patients almost all of the time, as opposed to the first two years in the classroom.  At the time when empathy is perhaps needed the most, both for the students and for their patients, is when they have an increasingly short supply of it.

I was reminded again today that the benefits of empathy are too great for it not to be taken seriously by all of us.  I am a big fan of Eric Barker’s Barking up the Wrong Tree blog and learn something routinely from his weekly emails that I receive.  This morning’s blog/ email?  3 ways that empathy can improve your life.  It was honestly too important and too relevant not to share, especially once three different Tweets were in my timeline this morning discussing aspects of clinical empathy.

The real meat in his blogpost, and that I will not rehash entirely here, is that it is possible to “grow” your empathy muscles- and most of the ways in which this can be done aren’t that difficult or time consuming.  The actions fall into three broad categories:  Listen, meditate (especially loving-kindness, or Metta, meditation), and expose yourself to different ways of living.  New experiences and different ways of living also improve creativity, meaning they also play a significant role in fostering progress and change.

For the parents out there, if you want to foster empathy in your children, it appears you perhaps should give in to their pleas for a dog.  Music lessons and unstructured play time (something that seems to be disappearing) also are important in development, so I am grateful my Mom provided all three of these.

Now, go find a way to hang out with some different people and listen to them.  It’s good for you.

Shame on you. Or perhaps shame on me?

“Vulnerability is the birthplace of innovation, creativity, and change.”

I was introduced to the work of Brené Brown just before the publication of her book The Gifts of Imperfection.  If you haven’t come across her work via Oprah or another major media outlet, Brené has a PhD in social work; her area of emphasis in her work is shame.

Yes, shame.

I Thought it Was Just Me was life-changing reading for me.  It was that big. As I was reading her work on shame and the quest for perfection (and both of their complex relationships with power structures), I saw our medical education system.  I saw so much of surgical education in particular, and could attach names to the pictures of “parents” (senior residents, faculty members) who adhered to the shame and blame paradigm rather than fostering compassion and a healthy sense of guilt.  When my colleague Will Elder was conducting interviews for our work on disruptive surgeon behavior he brought back to me the use of the word “shame” by one of our interviewees, who was describing the educational philosophy ascribed to by disruptive faculty.  On that day I knew we were on to something big.  I still believe that.

Brené describes shame as “the gremlin who says, ah-ah, you’re not good enough.”  Here’s the thing about shame:  it has lots of dirty side-effects. Shame increases dysfunctional coping, be that addiction, violence, eating disorders…things that people do to maintain disconnection from the world around them.  In our profession, shame looks like burnout and impaired physicians, and the perfectionistic tendencies of almost all of us in medicine put us at higher risk than the “average” person.  Our culture and ourselves provide a set-up for us to self-destruct- and the data show that many (too many!) of us do just that.

Since my initial reading of Brené’s work, I’ve committed to trying to change my corner of the surgical world by making it a place where we strive to say, “I made a mistake and I’m going to do better” (guilt) rather than, “I am a mistake and can’t do better.” (shame)  Like any parent or any human, I’m not perfect, and some days I am very, very far from perfect in leading that culture change.  I try to provide a safe place for my trainees, particularly the students, to talk about the “hard stuff” that is inevitably part of medical education.    And, to be completely transparent, I started this blog in hopes that it could be an antidote to shame as colleagues read it and think, “Yeah.  Me too.”  The most rewarding part of my electronic relationship with you, dear reader, over the last year and a half has been how many people have told me they’ve really connected with something that I wrote here.  I have weeks that I suspect my crazy ideas here are more impactful than a great deal of my academic work.  And I believe that my vulnerability here has been the nidus for a tremendous amount of innovation, creativity, and change.

For those curious about Brené Brown’s work, this TED talk is a terrific introduction to her ideas.  And, of course, as a Texan she tells great stories.

Our house is a very, very, very fine house

Last week I spent three afternoons in a communication skills training course.  I had two real motivations for doing this, one related to my leadership role in the Department, the other simply because of my constant quest to find ways of doing things that are just a little bit better than what I’m doing.  At the Departmental level, I’m assessing what will be the best option for us to have in place for communications training for all of us- particularly with a view to creating shared language for our teams.  So, yes, trying to figure out how to do that best for all of us and our patients.

One of the best pieces I came away from the workshop with relates to patient/ family communication and was referred to by our fearless facilitator/ teacher as the “house model.”

Since we’re talking about effective communication, let’s be clear.  Nate didn’t mean, and I don’t mean, this House:

Negative role modeling, perhaps?

Negative role modeling, perhaps?

This house model, used effectively, gets us to a place of shared decision making with patients and families (credit to Bhang and Irengui for a less colorful but equally visual initial version of this):

House Model of Shared Decision Making

House Model of Shared Decision Making

If you look at this, it’s almost intuitive.  It certainly makes good sense.  For me, it put all of this information together in a way that I hadn’t synthesized it before- and perhaps most importantly that can be easily visualized.  If you think about a truly great discussion you have observed or had with a patient and/or their family, all of these things were present to help get to shared decisions consistent with the patient’s goals for their care.

The reality that often intervenes, though, is that the non-medical participants in the discussion get overwhelmed by the medical facts, and they don’t want to question the authority of the physician providing that information- or let us know that we’re speaking fluent doctor and gibberish for a normal human being.  And it’s too easy under pressure of time or emotion (feelings are SCARY- and they require time) for the medical participants to skip the “patient perspective” part of the discussion.  If you use the diagram I’ve drawn before, shortchanging either of those pillars gives you a lopsided house, a lopsided recommendation, and an incomplete ability to truly share in any decision making that occurs.

I go back on service on Tuesday, and I’m going to put my House diagram up in our call room as a reminder to myself.  I might even draw a second and/or third version of what it looks like when one side of it falls down as a reminder.  And I’m going to try really hard to consciously use these concepts over the next few weeks.  I hope that you’ll join me.

 

Building the perfect beast

Last week while I was off on Amalia’s Spring 2015 North American Tour, one of the highlights was moderating a breakfast session at the American Burn Association with the theme of “Building a high-functioning team in stressful environments.” We had a great group in attendance with diverse areas of practice in the Burn Team, with lots of wonderful ideas contributed from varied practices. I was fortunate as well to have a highly experienced nurse manager and a seasoned social worker (both of whom are already friends of mine) who helped me to re-direct the conversation during those inevitable moments when it was digressing. You know, human factors fallibility and all…

To prepare for the session, I did a bit of homework, trying to find key points and common themes in the business literature about developing high-functioning teams. Characteristics that are identified in many studies include the following:

  • Common purpose- For the burn team, this is built into why we show up to work every day.  We want to improve the lives of burn patients and their families.  Fin.
  • Clear roles- Who’s on first?  Again, within the burn team, this hopefully comes with the territory.  I’m a terrible bedside nurse and an amateur mental health provider, but I like to believe I’m a good surgeon and physician.  Airing our own dirty laundry, roles have been an issue as we try to move towards a two-attending system in our Unit; we’ve had many questions about who nurses should actually take questions to, and this is understandable for a developing system (and something we are actively working on).
  • Accepted leadership- Lots of subtleties to this one- it’s not just the “who is in charge” issue I take about above, but extends to the leader being perceived as effective by the team members. That trust takes time to build and isn’t guaranteed.  As a leader, there are plenty of things you can do to enhance that trust-building process and to move towards being an accepted leader, but that’s a blog post for another day (and, honestly, it’s a lot of hard work…so be ready!)
  • Effective processes- What I love here is that it’s not just about knowing what works and how to get there from here- it’s also about the constant reassessment of how we are doing things and if we have room for improvement.  If there’s one area in my clinical life I tend to lose sleep over, it’s how we can do things better.  It’s part of our unit culture, and it’s part of why we’re just under a month shy of going 600 days without a CLABSI- we figured out how to do it better!
  • Solid relationships- You don’t have to be BFFs with everyone on the team.  In fact, it might be better if you’re not.  Words that came up frequently in our breakfast discussion included “respect,” “trust,” and “reliability.”  It is entirely possible to respect someone but not be friends with them.  Without respect, though?  Dead in the water.
  • Excellent communication- Again, this was a recurrent theme in our discussion, with an emphasis on the two-way nature of communication between the team and the leader, and the importance of leaders (physicians, in this case) being receptive to communication.  If you question the importance of communication, this 2012 HBR piece shows that the single most predictive factor in team success is communication.  Remember: energy, engagement, exploration are the keys to communication success
    • One of my favorite tricks that I learned from a very wise surgeon (aka Jeffrey R. Saffle, my retired practice partner) is to partake of “bedtime phone rounds” at 10 pm each night with the ICU nurses.  If they have little stuff going on, they’ll hang on to it until you call.  It helps to ward off many things during the night.  And it reinforces that you are there for them and the patient.  

Are there other characteristics that you’ve seen in your work environment that have contributed to an incredibly successful team?  And how sensitive are you to when one of the “secret sauce” ingredients is missing?

More on effective leadership soon…perhaps in a couple of weeks.  I have other ideas stored up from my adventures!

 

 

Taking chances

Well, I have either stepped into it big or I’m going to be a hero.  The outcome remains to be seen.

Why, you ask?  Yesterday afternoon I convened a group of individuals to initiate our process of rediscovering what professionalism means in our perioperative environment- what it means for this delivering care, for those receiving care, and for the process of that care.  In short, I’ve convinced an amazing group of people that we should tilt at the windmill of culture change.

As we all filed out of the meeting, I was filled with gratitude for this group coming together.  I was filled with humility that we have a group of people who are willing to commit time and energy to this project.  And then…well, honestly, I was filled with a little bit of fear because I realized that I’ve just taken on a project that is the equivalent of a balance beam routine with maximum possible points for difficulty.  Big risk, big rewards.  Or big risk, big crash.

Now that I’ve had 24 hours to reflect, I realize that by swinging for the fences with an amazing team that we will be positioned to generate amazing amounts of good.  As I told them, I have no expectations that this will be easy.  I have no expectations that this will be seamless (“My entire life is constantly in beta testing, and this is no exception.”).  What I do expect is that we will have a powerful voice from a group of thoughtful, visionary individuals who can make a real difference.

For our Council, and for anyone else embarking upon a new adventure this week, I offer you some of my favorite wisdom from Teddy Roosevelt:

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

Courage, friends, and onward.