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?

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.

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.

 

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?

 

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.

The secret ingredient

A week and a half ago, the Times published this op-ed that eloquently discusses the current obsession with metrics in healthcare and education.  Most importantly, Dr. Wachter manages to thoughtfully address the fact that most of our metrics are fundamentally flawed- but that doesn’t mean that our patients (or in the case of education, students) do not deserve quality from us.

Wachter’s piece, of course, comes out on the heels of multiple recent discussions about burnout in healthcare, and among physicians in particular.  It’s not that physicians don’t want to deliver high-quality health care- we do, and we want to provide high-value care as well.  But, again, the metrics are fundamentally flawed, so things we’re supposed to be doing to capture quality of care are often (1) unsupported by evidence and (2) incredibly cumbersome.  Anyone who has dealt with the Epic EMR knows what I’m saying here; while Epic is great for getting the “Meaningful Use” boxes checked, I often can’t tell a thing about what’s going on with a patient after reading a templated note that contains all of the requisite billing and MU elements.

The quote from Donabedian that is embedded in Wachter’s op-ed that was most striking to a few of us (I know that two of my respected colleagues commented on it on Twitter) was, “The secret of quality is love.”  I’ve spent the last week really pondering that sentence and what it means for us in healthcare, for those in education, and in particular for those of us who work in the liminal space of medical education.  Last night I was talking to my Mom about my belief that we all have to do a certain amount of stuff that we just have to do as part of our job- what I refer to as “eating your broccoli” (no offense to brassica vegetables). However, in a high-functioning system when we are established in our careers, we get to spend most of our time focusing on the things that light us up.  We become primarily busy doing those things that we are fundamentally excited about getting out of bed for on most days.  Chances are that those things we’re really passionate about doing still have aspects that can make us a little crazy at times- but because we care so much about what we’re getting to do, those annoyances are magically diminished. Linking this concept back to the topic at hand, because we’re so enthusiastic about what we’re doing, we likely do a better job of whatever that magical thing is.  Thus love (or passion) = quality.

And maybe, just maybe, getting to do those things is a remedy for burnout as well.

“Not all of us can do great things.  But we can do small things with great love.”- Mother Teresa

And that, with any hope, is the secret ingredient to all of it.

Things I’ve seen millennials doing right this week

Disclaimer: I have previously blogged on the topic of millennials and expressed my support for generational evolution.

After reading a column in General Surgery News in which the work ethic of the “youngsters” was again denigrated, my friend Justin Dimick commented on Twitter:
“Why does no one blog when they “catch” a millennial doing something right?”

His point is a valid one- while all of us seem to make plenty of comments about “these kids today…”, we seldom talk about the great things we see them doing. Rather than being moved by curiosity about people who were raised in a very different time and place than those of us born before 1970, we ascribe laziness and bad intent to them. Never mind that laziness and bad intent can be found anywhere if that’s what you are seeking.

So, what have I seen millennials doing right in the last couple of weeks?

  • I’ve seen them doing many, many things (some of which appear to be small things, relatively speaking) with great love.
  • I’ve seen them challenging themselves in ways that make them a bit uncomfortable, be that trying something new in the professional arena or declaring, “I am a runner!” when that’s an identity they’ve never considered before.
  • I’ve seen them being incredibly curious and creative. Y’all know this is how progress is made at a societal level, right?
  • I’ve seen them giving generously of time and/ or money to causes they are passionate about.
  • I’ve seen them teach and learn in ways that are regarding and collaborative.

Yes, I know that none of those are a terribly specific example of things I’ve seen Millennials doing right recently, but the general themes help to highlight the point that I want to make…the 20 and early 30 somethings are the future of our planet, the future of our profession, and in many ways our own future.  They are, just like those of us for whom 40 is well in the rearview mirror, people.  They- and we- are all basically good, and we all have the occasional “off”day because we are human. We- and they- want to help make the world around us better.

I suppose some want to take a single incident and use it to generalize about a group in a negative way, and that is certainly their prerogative.  As for me, I’ll keep looking for the light, looking for the good things that our millennial colleagues, and the rest of us, are out there doing.  That’s my prerogative- that, and closing the 2015 blog posts with music from my senior year of college.  Ah, the 80s…good times.

 

 

With a bounce and a thud

A few weeks ago, I had an experience I have not had in a while- and when I say “a while,” I mean in 5+ years. It’s an experience I believe is important to share with young leaders because what it really highlighted for me is that leadership isn’t always seamless and easy, particularly when you are bringing new and relatively foreign ideas to a group of people.

I’ve spent the better part of the last almost-two years pushing the envelope on how we define professionalism and what the system to support the ideal professional environment looks like. I’ve talked about it in multiple venues, and I would like to believe that my talks were (mostly) not scary to people and didn’t totally push them outside of their comfort zones. To be completely honest about my bigger administrative efforts, this was the one that scared me the most, primarily because it was the one that I felt had the most potential to upend people’s basic world views. I have persistently highlighted that we didn’t start on this because there is a ubiquitous lack of professionalism or because we have a glut of disruptive surgeon behavior.  Instead, we want to find ways to recognize the spectrum of behaviors, reward those who are doing well on that spectrum, and find ways to help those who are not.  And apparently, even though there are some who will need support, this didn’t scare anyone into silence or confusion (at least not yet).

Then there was this recent clunky presentation about the state of the education enterprise in the department, including ideas for ways to guide us into the future.

Did I mention the word, “Clunky”?  That’s my way to telling you that it wasn’t a wholesale disaster, nor was it anything near a raving success.

So, what went wrong?

Was it that I didn’t show funny cat videos?  With the audience I had, I’m reasonably sure that’s not it.

While I did bring something to the table, it was definitely something that required more than five words.  In fact, I think that’s probably where the wheels fell off of the wagon.  I went in showing people quite a bit of information they have never seen before (because it’s never been collected before into a single product).  That alone presents them with a challenge to process that information.

Then there was my own supplementation of the information with a series of completely new ideas.  If we don’t fully understand or recognize the “old,” how can we possibly be asked to effective consider the “new?”

While I did my best to listen actively, at the end of the day there was simply an overwhelming amount of information to be defined, interpreted, and processed by the other folks at the table.  This graphic from the HBR really helps to highlight what happened with the dynamic in the room.  Bottom line:  I went in speaking a somewhat foreign language, then ended up speaking a foreign language incomprehensibly to the audience.

Do I feel like I made an outright mistake with my preparation?  I honestly don’t think so.  Do I feel like I made a mistake in terms of volume of challenging material delivered?  In hindsight, yes.  That was what resulted in a  bumpy landing, and it also has given me an opportunity to try to acquire more information to help my audience understand what I am talking about, and in turn to allow us to have the discussion we deserve to have around this stuff.

Always learning…

 

It’s time for a time-out

Anyone who has been in the OR or in the ICU during a procedure is familiar with the concept of the “time-out.”  It’s something that has been around for a number of years and came into being as a way to enhance patient safety in the operating room.  The operative time-out itself continues to evolve, with many surgeons developing an “extended time-out” checklist for their OR, something I can definitely see benefit to doing.  For the last week, I’ve experimented with a variant extension to the time-out; when we were at the American College of Surgeons my friend  Mary Klingensmith Tweeted a challenge to the surgical education community to incorporate

an education time-out at the beginning of cases for their learners.  I’ve been trying to find ways to increase the teaching focus in the OR, and this seemed an almost foolproof way to do it.

The education time-out in our OR occurs just after the patient safety time out.  I identify each resident of medical student on the operative team, and I challenge them to tell me what their learning goal is for the case.  Goals provided by learners last week were sometimes technical, sometimes about decision-making, and sometimes related to the patient’s overall medical status but have little to do with the operation itself.  During the course of the case, I seek to address the questions raised by each learner, using a largely Socratic method (yes, I am still asking questions of them!).  What benefits do I see a week into this “experiment”?

  • The students and residents are pushed to be self-directed learners, and to articulate how they are guiding their learning.  I’m not identifying their goals, they are.  This is critical if we are going to “raise” life-long learners.
  • Having the learning goals provides us with a focus for the case.  While I like to think that I’m mostly above-average in taking time to teach in the OR, I have definitely noticed that this keeps me on-point.
  • The entire team is learning from one another, including our anesthesia team members and our scrub techs and OR nurses.  While patient care is still our #1 focus, the presence (and use!) of the education time out raises the perceived importance of education in what we are doing every day.

I’m still trying to perfect the system, and I am curious to take a good look at how it impacts both teaching and learning in the OR over time.  From a subjective and personal evaluation, I’m finding the education time out to be an important improvement in my work as both a clinician and an educator.  Surgical teachers, give it a try and I hope you’ll share your experience.  Surgical learners, encourage your teachers to try it. They might just find themselves with an important new teaching tool!