What if it’s not our fault?

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

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

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

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

On to Twitter conversation #2:

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

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

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

What if it’s really not our fault?

Starting them young

How many of you saw this study about emergence of gender stereotypes and intellectual capacity that came out on Thursday?

Actually, let’s roll back to two years ago when the same group published this study on expectations of brilliance and their relationship with the number of women in scientific fields.  The summary is that fields perceived as requiring brilliance or genius tend to be male-dominated, while fields requiring hard work and empathy have better representation of women.

I’m grateful that the authors went back in to try to figure out when this happens; apparently, it’s somewhere between kindergarten and first grade, give or take.  Girls start picking up social encoding that boys are the ones who are “really, really smart” and the logical side effect of that is that girls stop pushing themselves to do those things that they think require being “really, really smart.”  I suspect this happens in a variety of ways- through the media, through acculturation, through implicit bias.  While I didn’t get messages at home that girls couldn’t be “really, really smart” (in fact, quite the opposite as I took everything in the house apart and climbed trees while wearing dresses and wasn’t told that girls weren’t PresidentSurgeonCowgirls), I definitely suffered bias at school in math.  Every time we would move- which was frequent as evidenced by 6 elementary schools in 5 years- I would get put back to grade level in spite of documentation that I was usually 2-3 grade levels above.  In hindsight, I have to ask, “Would that have happened if I were a boy?”   The reality is that the answer is, “Probably not.”

The bigger thing (since y’all know I try to be solution focused around here!) is to think about ways to (1) inoculate our girls against this and (2) “rescue” those who are already older than age 6.

The BBC published this helpful guide the day after the Science study dropped last week.  There’s a reference in there to A Mighty Girl, which you can also follow on Facebook.  I’ve followed them for a while, and even being a few years older than 6 routinely find their posts to be inspirational. We need to focus on the importance of doing hard work that we’re passionate about, regardless of gender. We need to remind each other when we’re doing hard things well and having brilliant ideas.

Now, let’s all go out there and bust some assumptions, shall we?

Searching for meaning in it all

If you’re not someone who reads The Oatmeal on a routine basis, I’m not going to chastise you right now (though having a baby vs. having a cat is fantastic and you’ve totally missed out).  Instead I’m going to refer you immediately to a recent post on unhappy. (h/t Jessica Blumhagen, excellent surgery intern and human)

Now that you’ve read that, I want you to think about if you are truly, completely joy filled every moment when you are doing the things in your life that mean the most to you.

I’ll start: I’m not.

Do I have those moments of indescribable joy when I’m doing my clinical work, when a learner has an “Ah-Ha!” moment, when I finish a half marathon…you know, those things that I find to have meaning?

Sure, I do.  But it’s not every single minute that I’m there. Some days it’s a vast minority of them.  Recent example: I ran the Bozeman half marathon on Sunday morning after a fairly tough call week.  It showed in my performance, which was still a strong run (just not my best). I had LOTS of not-so-fun, definitely not joy-filled moments during the run, even though the scenery absolutely helped. When I was 100 yards from the finish line and looked over to see my mom and my Olivia-dog? Joy.  And a reminder of my accomplishment, something I am lucky to do.

And during my Sunday run, as we’ve all had in the midst of meaningful activities when we get into a “zone,” I also was in that amazing state of flow. It’s a state that as surgeons we find ourselves in during the middle of one of those great cases, when it’s all just going and you’re completely wrapped up in it and nothing can get into your bubble. It’s something that my running friends will recognize when you realize you’ve just clicked off 3 or 4 miles seemingly effortlessly.

I love the idea that to achieve flow that you need to do things that are challenging to you- it’s not the easy stuff when it happens. Matt Inman’s description of being “perfectly unhappy” aligns nicely with that idea when he talks about running 50 miles, reading hard books, and working long days.  I think that his comic struck a nerve for me because distance running (not 50 miles!), reading literary fiction, and well…y’all know about my job…anyway, I understood what he was saying about doing things that are meaningful to us and the importance of that even when those things are hard.

I’ll give my usual disclaimer: your meaningful isn’t going to be my meaningful. You may not run, and you may not love complicated books, and you may not have found “your” career niche.  That’s okay, and it’s important that we each be a little different from one another.

But I did want to remind us all (and perhaps maybe myself more than anyone right now) that it’s not going to be fun every day and it’s not going to be easy every day.  What it should be every day is a celebration of doing something that is meaningful to you. My new going to bed at night question that I ask myself is, “How did you show up today?” It provides me a compass for meaningful activities every day, keeping my focus on doing those things that I love.

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(And thanks to Susan Piver for this lovely thought that was perfectly timed for my post. THIS is why we keep doing the hard and meaningful things.)

 

 

Routine Vs. Ritual

Confession: I have a strong tendency to rebel against structure; structure and order simply are not my default modes of living and working.  Yes, I’ve learned to do work within structure and in a way that is orderly, though that is primarily a way of controlling the chaos.  If you look at my weekends when I’m truly off, about the only things you’ll find on my calendar will be “run” “yoga” and (during the appropriate season) “symphony”.

Someone recently observed that I’m reliable about getting my runs in, about writing, about walking Olivia, about going to yoga, amongst other things, and that demonstrates that I am committed to structure and order.

I, of course, argued against that idea, with my argument founded in how I differentiate routine, which is definitely about order, from ritual in my day-to-day life.  See, a routine is defined by pattern and regimen, and it’s characterized by a certain ordinariness (drudgery even?). Routine is doing the dishes after supper, or putting the recycling can out on Sunday nights. Routine is that weekly meeting that you are obligated to at work.  Routine is fixed and rigid, and I had a moment of joy when I saw that Merriam-Webster defines it as “a boring state… in which things are always done the same way.” Routine, in my mind, is obligation.  It’s the “must do” stuff.  It’s what sometimes gets referred to as adulting, which is an activity I’ve come to realize is completely overrated.

Why do I think of ritual differently, when it has some of the same characteristics in terms of patterns? Ritual’s word root is shared with rite, which has a spiritual or religious overtone. It’s more ceremonial, and rites can be part of a celebration. If you look at those habitual things that I’m reliable about, they are things that bring me joy, that I don’t consider drudgery (okay, there’s that rare run, but generally speaking…). They are activities that leave me feeling better than when I started them, that often challenge me, that are the foundation for (hopefully) making me a better version of myself. While I still tend to treat them as obligations, they aren’t the obligations that I see on my calendar and start secretly hoping that they’ll be cancelled.  Yes, there is structure around running on Saturday mornings at 7 with my running tribe, but there’s no question that it’s a challenge that I love. There’s structure around hurrying home after my run for a quick shower and snack before Restore Yoga, but there’s no question that I always leave yoga feeling better than when I got there. There’s structure around walking Olivia every single morning when we get up, but there’s such shared joy in our outdoors time together that I would be foolish to not be part of it.

I suppose the challenge becomes in trying to turn some of those routine things into ritual, which is entirely about changing mindset. Maybe tomorrow I’ll look for some joy in doing dishes…

 

Tomorrow is another day…

Why do today what you can put off until tomorrow?

Why do today what you can put off until tomorrow?

It’s an activity that looks different for each of us- and it only applies to self-directed responsibilities.

It’s been identified as a basic human impulse, and one that we know is inherently irrational.

We do a remarkable job ignoring its consequences.

When I was in college and needed to write papers, it usually resulted in mass quantities of baked goods or a large roux pot of étoufée.

Now?  Well, now it occasionally (thought not always) looks like a blog post.

We are all, each of us, procrastinators by nature. The reality of a future benefit of whatever action or task we are putting off is far less significant to us in a given moment than the potential immediate gratification of something else we could do right now- particularly if the delayed action or task isn’t something we actually enjoy.  Those things in the future tend to be pretty abstract as well- and they are certainly more abstract than something sitting right in front of us.

Sometimes procrastination can be used to our advantage; poet David Whyte appropriately mentions that it may provide time for ripening of ideas. He also counsels that we should use procrastination as an opportunity to careful sit with why we’re delaying the action or task in question, reminding us that sometimes the time that it gives us provides us interaction with something much bigger than ourselves.  I’ve felt this more than once when I’ve given myself a bit more time than I might have liked while working on a manuscript, only to find that when I finally do get my backside into the chair that it magically ends up “just right.”

However…we all know that procrastination isn’t entirely to our benefit.  We know we need to keep up with our documentation, but sometimes the Epic inbox is just so…overwhelming.  We know we should respond to a couple of emails from colleagues, but we’re going to say “no” to something they’re asking us to do and we don’t want to disappoint them. The phrase I’ve come to use around the types of tasks we tend to put off even though they are necessary?  We have to eat our broccoli (or some other vegetable that may not be your personal favorite).

This week the HBR website had some tips and tricks on how to beat procrastination for those times when it’s not working in our favor. I have a favorite from each group- in the first group, it’s thinking about how great you feel when that task is completed.  Admit it, it’s nice to have your Epic in-box empty. For the second group, it’s figuring out the first step that you need to take to get started; this concept works best for more abstract, bigger things (like starting a manuscript).

So, what are you going to get done today that you’ve been putting off?

 

 

 

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.)

 

 

Zzzz….

I would start with a few comments about the Daylight Savings Time change that occurred yesterday, though I try to be civil here.  Let it suffice to say that I don’t enjoy my dark early mornings that are the “new normal” for a few more weeks again. I always whine a bit about this Spring change, particularly because the bases for it are weak at best. And while I seldom rail about sleep disruption from my travels, the energy drain I tend to experience from the time change is huge. And, of course, that has the potential to really impact my work.

Last month the Harvard Business Review published a terrific summary reviewing the link between effective leadership and getting adequate sleep.  I do think that sleep piece is without a question a big piece of it, though I also believe that fatigue in general affects our ability to engage in the four types of leadership behavior that the authors describe.  There becomes a domino effect where fatigue directly results in disengagement, and disengagement is intimately related to burnout. While a great deal of the discussion about residents and duty hours has been focused on the impact of adequate rest and safety, the truth is that the impact of sleep deprivation throughout medicine is far more insidious than we’ve previously estimated.

When I was in my 30s I honestly wasn’t as protective of my sleep- perhaps because I spent the first half of the decade finishing my residency before workhour restrictions went into place. As I’ve become a bit wiser (and, in association with that, a bit older), I have learned to better prioritize my rest, though I’m still not as skilled as I would like to be.  No matter how much I look at all of the professional advice- get off of your screens, turn the lights down, don’t eat late, don’t exercise late- some of those things simply can’t happen for me all of the time. When I’m not faced with clinical demands I certainly do my best, but it’s a very imperfect best. And while I have been largely successful in creating a 10 + 10 (meditation + free writing, 10 minutes each) morning ritual for myself prior to my morning walks with Olivia , I really wrestle with what my evening ritual could and should look like.  I’ve generally stopped sending emails after 830 pm.  I’m generally off-line an hour or more before I plan to go to bed. I generally read for 10-30 minutes before bed, depending upon what time it is when I sit down with my book and when the alarm will go off the next morning.  Nothing in the evening has stuck for me as well as 10+ 10 + dog walk, however.  I’m still working on this concept to figure out what works for me.

I’ll close by saying that I’m a realist.  I take call 1 in 3 averaged over the year, and when I need to take care of patients sleep becomes secondary. It doesn’t mean I don’t take a power nap when I get the chance (I love power naps!) or make a conscious decision about managing my energy in other parts of my life (yes, I do skip runs if I haven’t slept well). I’ve made a conscious decision that it’s okay to stop working at some point in the evening, especially because I’ve embraced that my do-to list won’t go away completely anytime soon.

And with that, I should close.  It’s after 830 MDT, after all.

Happy resting!

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.

 

I really mean it this time

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It appears that almost three weeks ago I committed to getting back to posting on the blog.

I also appears that I have not been successful in posting for the last three weeks.  I’ve come close many times and just haven’t successfully overcome the “backside in chair” phenomenon that is required to generate blog posts or manuscripts or anything along those lines.

I could make up some excuses, but they would be just that.  And they would likely be silly.  I’ve had a fair amount of the ever-important time to think, I haven’t been that overwhelmed with work, and I haven’t been thrown any curveballs that messed up my game.

Instead, I’ll simply come back to writing, sharing the two foci of that recent time to think.

#1 On the concept of “preventing too many activities” (Item #3 of the 7 Characteristics of the Dharmic Person): Maybe this is my “excuse” for the blogging break. I’ve been really conscious lately of saying no to things that really don’t align with my goals and priorities.  I’ve also been spending time thinking about those things that don’t light me up like they used to and finding ways to effect change there. And, perhaps most importantly, I’ve been focused on not having too many things going on at a given time (and yes, that includes my tendency to multitask).  This idea of being really intentional and staying out of overwhelm is one that just makes sense to me where I am right now.  I do still care about the blog…I’ve just put other things higher on the list the last few weeks.

#2 On being grateful: I’ve spent the largest portion of my time lately considering how incredibly grateful I am. Part of this has been driven by travels in which I have consistently been surrounded by friends; from Baton Rouge to Austin to Bozeman in the last 5 weeks I have eaten very few meals alone, and I have been able to treasure time with amazing people who have become part of my life in a rich variety of ways. I’m fortunate to have the opportunities that I do to travel to beautiful places.  I’m fortunate to be able to run and do yoga and play outdoors. I’m fortunate to have clinical and administrative jobs that excite me and constantly challenge me, and to work with people in those roles who “get it.”  I have managed to revel in the little joys of friendship and adventure, and I’m grateful that I’m able to recognize how fortunate I am.

So, with that, I’m back.  And I mean it this time.