Perfect Circle

Wednesday was a bittersweet day for me.

I’ve previously mentioned Danny Custer, whose last day operating at Baylor Scott & White was Wednesday of this week.  Danny had a remarkable career as a pediatric surgeon.  He was also our clerkship director when I was a medical student, and proved to be a huge influence on me. Even though I had no intention of becoming a surgeon when I started medical school, between he and Sam Snyder (and some really spectacular residents, including the husband of a college roommate) I was a “clerkship convert” to this crazy life.  Anyone who has been in my OR when I’m directing how long I want suture to be cut has heard the words “bunny ears” more than once.  I inherited that phrase from Danny. Danny was amazing with families, adored the children, taught with the patience of a saint, and made every day of “work” an incredible amount of fun.  His passion for his calling was contagious and I always, always mention him as part of my own story in medicine and in surgery.

Wednesday morning I got a text from one of my former student mentees who is now a resident at Texas A&M/ Scott & White. Kyle went to Temple knowing that Danny was one of my mentors, and I appreciate that he texted me the first day he operated with Danny as an intern.  Wednesday’s text was to let me know that it was Danny’s last day and that he would be operating with him for his last case.

My first reflection was one of gratitude that I have mentees out there who stay in touch.  Those moments are why those of us who teach pour our hearts and souls into what we do.

My second reflection was also one of gratitude that Kyle was operating with Danny on Danny’s last day as a surgeon. There was something incredibly special in knowing that someone I have influenced for good was helping to close out the career of someone who had such a positive influence on me.

Bittersweet.  And an absolutely perfect circle.

 

Coming clean…

Obvious confession:

The blog has been a bit of a ghost town for the last few months.  You’re aware, I’m aware. Twitter hasn’t been an echo chamber, but I’ve not been as present there either.

Not-so-obvious confession to most:

Professional life has been messy and hard, and I’ve struggled with how to process that. Heart and Brain provide a near-perfect summary of what it’s been like (though I’m not sure the brown stuff would have been quicksand had I drawn them).

Personal life has been fine, great even. I have professional friends whom I’ve entrusted with what has been going on and who have been amazing advocates and supporters. I have other professional friends who haven’t been in the loop on things but who have consistently reached out with a kind word when I’ve needed it most (serendipity, FTW!). I have running  friends who have stuck with me when I’ve stopped for an ugly cry in the middle of a 10K. I have friends who have been around seemingly forever who are simply there and constant and kind. While you might not think that in your late 40s your sorority sisters would provide a life raft for you, they have done precisely that. As I told one of them a few weeks ago, “ADPi has saved my sanity the last 18 months.” Mom is great and healthy.  Dad is navigating the indignities of Parkinson’s with grace. Other than Belle!’s anxiety (maybe she’s channeling for me?), the animal support team is awesome. If you look at the ledger strictly from this side, I’m incredibly fortunate, and I won’t deny that. I am grateful for all of these things every day.

Then there’s the professional side.  Lots of things on the “good” side of the ledger there too. I work with the best team that anyone could ask for.  I take care of the most remarkable and resilient people that I could ask to be entrusted to care for. It’s a rare day for me to walk through clinic or the burn unit without getting a hug from a patient, family member, or both. Outside of my clinical work, I’ve been entrusted with leadership roles that I consider both a privilege and an honor. Again, these are the things that keep me going and for which I am grateful.

And yet…there’s this body of literature (which I am in the process of contributing to) that describes why women leave academic surgery and academic medicine. That literature has become intensely personal over the last 6-9 months for me. I’ve found incredible irony that the system that I’m trying to help fix, to make more equitable, has nearly chewed me up and spit me out. While I always found it tragic that many talented women were exiting academic surgery, even 10 years or more into what should have been remarkable careers, I now “get” how this happens. I would be a liar if I didn’t say I’ve thought about walking off. I don’t do disappointment and disillusionment well.

So what?

I’m still working on the answer to this question. What I do know is that I’ve moved past taking it all personally and simply being hurt. If anything, I’m realizing how important some of the intellectual work that I started out to do a few years ago truly is and that it’s time for me to double down on those efforts. I’m focusing more on my core mission(s) and doing the things that are the most meaningful to me. And I’m reminding myself at the close of every single day of those things I am grateful for; there are plenty of them, and they help maintain that sense of purpose that I need.

If you’ll excuse me now, I’m off to tilt at some windmills.  Thanks for joining me.

May 2017 Reading Round-Up

Brand new month!

So what’s out there that is catching my eye?

We all spend quite a bit of time thinking about how to improve teaching of technical skills.  What about using video-based coaching to supplement OR teaching?

What does the public know (and want to know) about overlapping surgery?

The 2016 State of the Science articles for burn care are out. These cover everything from burn resuscitation to community reintegration, and are all important comments on where we are in burn care (and how far we have to go).

And bringing out my inner policy geek, here’s a great overview from Politico on what the impact is for the GOP if/ when Obamacare repeal fails.

Catching my ear is the “Up First” podcast from NPR. I seldom have time to listen closely to the news throughout the day, so this is a great summary of what’s happening.

Happy reading (and listening).

 

 

A slightly belated April reading round-up

I’ll start with an apology: I’ve not been on my A-game with keeping up with the blog lately. Lots of life distractions, many of which I’m hopeful will start to settle down soon.  It’s not been easy.

So, it is April, and a number of things out there have caught my eye.

The March print edition of JAMASurgery included this systematic review and metaanalysis of causes of attrition in general surgery residency. While I’m reasonably certain we can’t get the rate to zero because there are factors we cannot control, we must do what we can.

While we are all becoming painfully aware that too many narcotics are being prescribed for our patients, we tend to not have a good understanding of what constitutes too many or too much.  This study provides an important baseline for us as surgeons. I will also note that Annals of Surgery will have an ongoing series examining the opiod crisis from a surgical perspective.

We’re definitely talking more about delirium mitigation in our adult ICU patient population.  What about the children?  Apparently it’s a problem for them too (particularly with “inflammatory disorders,” which would definitely be my patient population!).

Going a bit outside of the medical journals, what’s next in hospital innovations to keep patients safe? I was thrilled to see my friend Amir Ghaferi‘s name as first author on this piece.

Pleasure reading?  Our book group is spending the next two months with one of my all-time favorites: The Amazing Adventures of Kavalier and Clay by Michael Chabon.  I am looking forward to re-experiencing it.

 

We’re all experts now

Or are we?

For my medical friends, we see it in the American patient predilection for paging Dr. Google. For those of us who follow the environment, we see it in the denial of climate change. And we ALL saw it in the 2016 election in the form of the echo chambers on both ends of political spectrum.

What is “it”?

Confirmation bias- that big, bad cognitive stumbling block that allows us to completely ignore information that doesn’t support our ideas/ opinions/ “facts”. Our brain is amazingly gifted at dispensing with inconvenient information, and confirmation bias, and neuroscience shows that we tend not to look for information that challenges our beliefs.

Think about that for a moment. When is the last time that you actively sought information that doesn’t align with something that you believe about the world? Be honest here. Oh, and think about how much you learned the last time that you did make that effort (because we know that confirmation bias limits our learning!).

It seems that the current political and social environment in the US has resulted in a flurry of writings about confirmation bias, particularly its impact on science and policy. While confirmation bias used to be a phrase that we mostly used to describe a failure to maintain equipoise as an investigator, it’s become a key part of the 2017 lexicon, particularly with the advent of terms like “alternative facts.” I have to admit that I’m not sure I feel any safer about people embracing alternative facts when we know that facts don’t change our minds.

Another often underestimated aspect of confirmation bias comes from deeply held personal values. Be it the risks vs. benefits of drilling for oil in the Arctic or how Planned Parenthood actually spends taxpayer dollars, many individuals have values-driven opinions that impair their ability to have meaningful dialogue around these topics (myself included at times). Instead, everyone fancies themselves an expert on topics that they aren’t, and instead of intellectual, meaningful dialogue we get meaningless and unhelpful shouting matches. Suddenly we’re back to that echo chamber of the 2016 election…

The medical tie-in for confirmation bias is, of course, when it impacts our diagnosis and management of patients. (Note: if you haven’t read Jerome Groopman’s How Doctors Think and you are in the medical field, you are doing yourself and your patients a disservice.) Certainly we base a great deal of what we do upon pattern recognition.  But what about those times when the patterns lead us down a primrose path that is…wrong?  It happens, even to fabulous clinicians.

How do we overcome confirmation bias if it is so insidious?

Simple.  Seek proof that what you’re thinking is a terrible idea.  Look for disconfirming data. Conduct small experiments that are capable of disproving OR proving that your idea is right.

In other words, prepare to be wrong from time to time.  It’s part of our human experience.

Ladies, get yourself a Girl Gang

I admit that I usually try to give you food for thought then let you draw you own conclusions and applications.

Tonight, on the eve of International Women’s Day, I’m making an exception.  I’m dispensing some invaluable career advice for my women readers, particularly those in surgery:

Get yourself a “Girl Gang.” If you are somewhere where one is already in place, find out how to become a contributing member. At all costs, though, find yourself a group of women who share your commitment to excellence.

This article examining mentor-mentee sponsorship and gender came to my attention over the weekend (HT: Susan Pitt).  She astutely pointed out that this gives us an “action item” for women in surgery- to do a better job with sponsorship as more of us move into leadership roles.

This came on the heels of my friend Harriet Hopf mentioning during a breakout session last Friday that she appreciated being asked to join a “girl gang” that we already had in place at Utah with the expressed goal of promoting one another for leadership opportunities and awards. She came here from an institution with plenty of women in her department and in leadership roles, so this wasn’t something instinctive for them to do. For those of us in departments and places with a paucity of women leaders, it’s critical.

How does our Girl Gang work?  It’s remarkably easy.  We watch out for leadership positions or awards (both within and outside of our institution) that align with one other’s skills and accomplishments, and we nominate each another. Also, if there is a recognition that one of us really wants, we have an understanding that self-nomination to another group member is encouraged, and they’ll take care of the actual nomination.

Certainly our effort focuses on a group of women who are at a certain stage of their career, and those people definitely comprise the active members of our Girl Gang. However, once you start doing these things for your peers, you realize that it’s easy enough to extend your influence beyond that core group. I suspect I’m becoming a bit notorious with some of our female faculty in particular for my “nudge” emails (“You are incredibly qualified for this…you should apply…how can I help?”). My basis for doing this is two-fold, and both are factual.  First, as women we tend not to apply for things until we’re overqualified.  Sometimes we just need someone to tell us that yes, we really are worthy.  Second, it helps take the stigma away of tooting your own horn– again, something that women are penalized far more heavily for than are men.

(Closing note: While our Girl Gang has focused heavily on promoting the careers of women, we are not exclusionary and we welcome allies. I solemnly promise that I’ve put men forward for awards, leadership roles, opportunities, etc…I just focus on it less because we’re nowhere near having a critical mass of prominent women in academic surgery.  Yet.)

March 2017 Reading Round-Up

Ah, March.  Here you are, and you didn’t even come in like a lion.  Thanks for that.

First, more information confirming my own bias that communication with our patients and families matters, not just for the fundamental “it’s the right thing to do” reason, but because it also impacts risk of postoperative complications.

This terrific Perspectives piece discusses the role of trainees in the changing medical care landscape in the US.

As my own team works to identify risk factors for delirium in Burn patients, this article with risk factors following colorectal surgery may provide us with some guidance.

Were you there for my friend Mary Klingensmith’s fantastic ASE Presidential address last April?  If you missed it (or if you were there and loved it), here it is in print.

Side reading: February’s book group book was Alexander Marra’s The Tsar of Love and Techno. VERY highly recommended.

Greater than, less than

“Who and what do societal and cultural institutions tell you that you are?” HT: Desiree Adaway

This question came across my Facebook feed this morning; in truth, Desiree Adaway posts provocative thoughts on a daily basis. The timing of it mattered because my thoughts have been marinating about a social media storm that happened last weekend and they have finally (mostly) become coherent enough to share.

I’m going to give the short version of what happened last weekend without any screen shots, mostly in the interest of not resurrecting the whole thing AGAIN.  Here are the key points:

  • White cis male surgeon posts an irrelevant and incredibly sexist response to an article on Doximity; he apparently thinks that his response constitutes “humor”.
  • Outrage follows from many women surgeons and male allies. Outrage includes LOTS of Twitter bandwidth and screenshots being shared of his comment with his identity. Outrage also includes people identifying his Twitter accounts and putting comments/ ratings on his practice social media sites.
  • Questioning of the level of outrage occurs with concern expressed that “this could ruin his practice”. Response from those involved is essentially that he earned the judgment.

Other than expressing my horror at his remark,  I largely stayed out of the fray because I couldn’t get entirely comfortable with what any further response should be.  Some of my colleagues provided thoughtful and eloquent responses on Doximity on the thread in question.  One colleague with a significant social media presence actually tried to reach out to him (I don’t know if she was successful or not). A colleague who pled for those who were publicly sharing his information to be thoughtful seemed mystified by the backlash.

And, towards the end of all of this social media hurricane, I hope I was able to crystallize many of the issues into one thing:

The comment implied to women surgeons that we are “less than” in some way.  It’s an experience that has happened to nearly all (if not all) of us at some point in our career-  we have been told, either implicitly or explicitly, that we aren’t as good, aren’t as qualified, aren’t all that merely because of our gender. For our women colleagues who are racial and ethnic minorities, they often are told that they are “less than” twice- once for their gender, and again for their skin color.

The truth is that unless you’ve been told that you are “less than” it’s hard to internalize what that experience is like.  The truth is that when you’ve fought your entire career to not be “less than” (which has often required being “greater than”), that yes, you are going to be outraged when someone publicly indicates that simply by virtue of your chromosomal makeup that you are “less than.” The truth is that many of us are tired of those messages of being “less than,” and we’re simply not willing to put up with it anymore- either for ourselves or for those around us. It’s not cute, it’s not funny, and it’s simply not okay.

Lest you think I’m trying to justify the public shaming that occurred, I’m not, because I’m still ambivalent about parts of it.  What I am trying to provide is a window on why the response was so furious for those who don’t get it. It’s only partially about the one statement, which reflects anywhere from years to a lifetime of messaging that we’re simply not willing to tolerate anymore.  Neither should you.

 

Wasting of time sitting still?

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

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

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

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

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

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

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

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

 

Reading-Round Up, February 2017 edition

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

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

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

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

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

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

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

Happy reading, all.