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.

 

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?

I’d like to phone a friend…

This piece in WSJ this week generated quite a bit of conversation on Twitter within my circles.

You see, at times there is still this culture around the idea of calling for help being a sign of weakness.  I still know of too many faculty (because more than 1 is too many) who have reputations for being bears when called in the middle of the night- a reputation I consider only slightly more favorable than those who are known for ignoring calls and pages outright. And I still remember what it can be like to be on the resident end of those phone calls; you know that you’ll get berated for calling, but you also know that you’ll be in even deeper trouble if you don’t.

Teaching our trainees to call us for help is important, both for them and for the patients.  The trainees need to feel supported and we have an obligation to the patients to direct their care.  Residents shouldn’t expect to be spoon-fed, and I know that most of our residents will tell you that the first question I’m going to ask after, “What can I do for you?” is going to be, “What would you like to do?” because I still want them to be problem solvers.  I just want them to know that they have a safety net, which results in the last question I often ask: “Do you need me to come look with you, or are you okay?”

An important piece that extends beyond training is by calling for help when we’re concerned that we are getting into a bad situation. When I was freshly out of training, I didn’t think twice about calling my senior partner to look at things with me in the OR.  I can only think of once the he scrubbed in; more often he gave me someone to bounce ideas off of, and he validated that I really did know what I’m doing.  In the last 6 months, I’ve called one of my partners for help in the OR when I had unanticipated and impressive bleeding while doing a trach (he scrubbed, we fixed the problem together, patient did okay), and that same partner called me to look at a patient’s wounds with him intraopratively when he had concerns. I recognize that this is part of the culture that we have within our practice group, and I’m grateful for it; it supports us in making the best decisions for our patients and providing them with the very best care possible. And, as was astutely pointed out by a former student who is now a surgical attending, we’re providing good role modeling for our residents and students that calling for help is, in fact, the right thing to do, and that you’re never too senior or too experienced to invite someone else in to a complex situation.

While I value the culture that the Harvard hospitals are promoting around calling for help, I worry that the “card” described in the WSJ piece may be a bit too directive.  I can think of many scenarios that don’t necessarily fit the items listed and in which a trainee might wonder if they should call.  Ideally, they need to add one more item:

If you think you should call, call.

(Or, as I explain it to our residents- I’ve never gotten upset with someone for calling.  I have become very upset with someone for not calling when they should have.)

 

The highway runs both ways

Many of you know that I have a strong interest in mentoring and the impact of mentoring on career development in academic surgery. I’ve been wrestling with this question in one form or another since the middle of my own residency.  It’s easy enough for us to be prescriptive about qualities of effective mentors or structures that foster effective mentor-mentee relationships.  What we focus on less commonly is the mentee’s role in the relationship; the reality is that a mentor can be the best mentor in the world, but if the mentee isn’t active in the relationship, it’s doomed to failure (see analogy here: you can lead a horse to water…).

Since the academic year is about to change, I figured there’s no time like the present to provide tips and tricks for being an effective mentee.  Full credit goes to some mid-career and senior women surgeons who I interviewed from 2013-2015, and who provided the following concepts of being an effective mentee.

  • Put yourself in the driver’s seat– No, I’m not telling you to boss your mentor around.  What I am telling you is to be clear about what you want/ need/ expect from the mentoring relationship.  Not only do you need to actively seek mentorship, you need to have a purpose in that relationship. If you come into my office and ask me to mentor you, I’m pretty likely to ask you to think about in what your goal is for our mentoring relationship…and send you away to think about it.
  • You are accountable, and it’s up to you to report back– Let’s pretend that you came to my office and asked me to mentor you, but you didn’t have clarity around what you wanted that to look like or what exactly you wanted from me.  I gave you the task of figuring that out and told you I was happy to meet again once your ideas are better formulated. In general, I’m not going to come find you to get some idea how your brainstorming is going.  It’s your job to do your homework (so, put on your thinking cap) and reach out to me when the time is right.  I’m not clairvoyant so I can’t guess, and if you do your homework then come back I know that you’ve got skin in the game. I’ll make time for you, and please don’t worry about me being busy- I am, but if you’re invested I am invested too.
  • Be receptive to feedback- A high-performing mentor will have to perform acts of radical candor if they’re doing their job effectively. That means that the feedback they give you may not always be sunshine, rainbows, and bunnies.  When I am having to give you hard feedback, I’ll do my best to deliver it respectfully and thoughtfully as long as you try to stay tuned in.  I know how challenging hearing negative things is because I’m not perfect either and have heard plenty of them over the course of my career.  I’m also giving you the challenging feedback because I suspect it’s not part of who you aspire to be, and my job is to help you be the best version of you. Oh, and after I say the hard things? Please act on them!
  • If I open doors for you and provide you with opportunities, please capitalize on them- This is self-explanatory.  Go out there and shine bright if I’ve sponsored you for something!
  • While this may be a long-term relationship, we’re not married- I know that you’ll likely outgrow me someday, or that I may help you meet the goal that you set in working with me as a mentor. If we’ve had a successful run together, I’m always going to be interested in what you’re doing, even when I’m not directly part of it, and it’s not going to hurt my feelings if you tell me you’ve got another mentor(s).  Quite honestly, my best success is shown when you’re succeeding, and perhaps when your own success exceeds mine.

Any other “best mentee ever” tips out there, readers?  Please share!

 

Don’t be Reviewer #2!

My friend Christian Jones and I have joked for at least a year about that one reviewer- you know the one- who provides you with those comments that either can’t be responded to without completely redesigning your study or who makes completely irrelevant comments about your manuscript (leaving you wondering if they even read it). Simply as a matter of levity, we’re referred to that person as Reviewer #2- and while Reviewer #2 in the style we’re talking about doesn’t happen every time, it happens often enough that the phenomenon is worthy of a “Do this…not that” list.  Hopefully it can also provide some guideposts for junior colleagues whoa re just starting to dip their toe into the world of serving as a reviewer, a task that can be wonderful, frustrating, rewarding, and sometimes even demoralizing.

As someone whose work is reviewed, it’s important to consider if it’s a bad (meaning negative) review because your work wasn’t up to the standard of the journal you chose (no, that retrospective review with 30 patients is not going to make it into JAMA), or because your work truly was lacking in quality in some way.  I always spend time reading the reviews and trying to figure out if the submitted work was deficient in the ways described by the reviewers.  Sometimes that’s true, and sometimes their recommendations/ comments/ queries enable me to submit a stronger manuscript.

And then there are the Reviewer #2 comments, which can range from questions that have nothing to do with your study itself, to “I simply don’t like it.”  How can each of us commit to not being Reviewer #2?

-Spend the time. Being a reviewer isn’t easy, and its honestly an honor. If you’re not going to have the time to devote to the review, don’t agree to do it.  Further, if you read the article title and realize you’re not interested/ lack expertise in the content, don’t agree to do it.  Get the idea?

-Do the manuscript’s hypothesis/ study goals align with the conclusions, and do the methods used make sense in that context?

-Do the results tell a “story” aligned with the hypothesis/ goals, and does that story support the conclusions?

-Do the authors overstate their findings in some way, making a MUCH bigger deal out of their study than it deserves? Alternatively, are the authors understating their findings in some way? Is this something novel or innovative that they should highlight more strongly?

-Have the authors appropriately noted the limitations of their study? And have they provided some idea of what might be appropriate “next steps”?

-Don’t overlook IRB approval- I’m often amazed at how many studies I review where the authors have forgotten to include this information.

-Be constructive, remembering that as a reviewer it’s not necessarily your job to “fix” all of the broken things in the manuscript.  That’s the senior author’s role and responsibility- though you can make suggestions in terms of what you think should be fixed.

If it’s not helpful/ actionable, don’t put it in your review (exception: if you have a complex question that is clearly beyond the scope of the study but you want to ask/ put on the author’s radar screen, it’s acceptable to put it in the review and state that you expect no response). Reviews are no place for snark.

Remember, ladies and gentlemen, only you can prevent Reviewer #2!

 

Don’t question me!

This week, I have heard two different stories about limitations being placed upon interactions with medical students by institutions.  To be completely honest, they both strike me as horror stories with a Draconian response to managing power dynamics.  First, I was told that at a major medical school that very strict limits were placed on what residents and faculty are allowed to ask medical students to do.  This was followed in short order by learning that at another medical school the resident or faculty member has to explicitly ASK the medical student if they can ask them questions to assess their learning.

I had recently been flabbergasted, reading about the climate in higher education at many institutions and concerns expressed by students about having their fundamental understanding of the world disrupted.  And now, this piece in The Atlantic talking about the damage being done long-term to learners who are being overly-protected in their university environments since their professors can no longer teach them how to think.

For anyone who has been wondering why their interns aren’t always well-prepared to be a doctor on Day 1, I may have hit upon the “why.”  I understand that questioning can occur in ways that are not conducive to learning and that can even be disrespectful to the learner in some way; I’ve seen it done.  This is the exception, however, and often occurs in conjunction with other marginally professional behaviors.  It seems that some medical schools have, in the interest of preventing “student mistreatment”, created an environment where their teachers are denied any of the tools available to assess clinical reasoning.  If I may ask a question, how am I supposed to assess a trainee’s clinical acumen if I can’t ask them to walk me through their thought process?

I spend a tremendous amount of time discussing that we are behind the curve in medical education, where we still focus on single right answers and MCQs to assess knowledge that is largely based upon retention of facts.  We test this way in a day and age when we all have easy access to facts, and in a time when the rate of knowledge acquisition cannot be matched by the human brain.  If we are going to move beyond testing for facts- knowing that factual knowledge does not necessarily a good doctor make- how do we prepare learners for a new world order focused on clinical knowledge application if we cannot ask them to solve clinical problems?

More importantly, how do we turn back the tide?  I’m not saying that we should yell questions at our students and residents, or that we should ostracize and humiliate them when they don’t know answers.  But as educators, if we are going to responsibly create the next generation of physicians, we must be able to engage in questioning in a way that is both meaningful and constructive.  Draconian solutions in which we’re simply not allowed to ask learners questions will have huge- and negative- impacts on the care we are all able to receive in time.

‘Tis the season…

…for residency applications.  Somehow this process keeps moving forward in a recurrent fashion even when I’m certain I’m not any older than I was when I first started as faculty 10 years ago.  Of course, I’ll do things every once in a while (see “run half marathon”) that remind me I am indeed 10 years older now, mostly because I’m slower and more sore the next day.

For those who are working on their residency applications, this time last year I provided some tips about writing personal statements.  That guidance all still applies.  I also left “have as many people as possible read your personal statement” off of the list, and that is also true.

However, there are other important pieces of the application packet, letters of recommendation being the one that often serves as the greatest differentiator between the many excellent applicants.

For students, here are things to think about when selecting your letter writers:

  • They will ideally be faculty who have worked with you closely in a clinical setting and can therefore speak to your clinical knowledge and skills.  When I am reviewing applications, I always slow down when someone can tell me that they directly worked with a student, particularly if they had fairly extensive contact in the clinical arena.
  •  A letter from a less-known junior faculty member who has worked with you extensively and can speak to that will usually hold more weight than a letter from a very famous senior faculty member who damns you with faint praise because they don’t actually know who you are.  There are some senior surgeons whose letters I almost uniformly ignore because they write the SAME LETTER for every student from their institution.  I scan to make sure it’s the same letter again (I have yet to be disappointed by this) then move on to the next letter.
  • You have a responsibility to ask someone if they can write you a “strong” letter of recommendation. If you were clinically mediocre and ask me if I will write you a letter of recommendation without clarifying that point, I may agree but you may not get the letter you would want.
  • Things to have ready when you want someone to write you a letter:  Your CV.  Your personal statement.  And I now always ask, “What do you want me to highlight in your letter about our time working together?”  That insures that I won’t miss the mark of how you are “marketing” yourself for residency.
  • Please give us plenty of lead time.  While I almost invariably get letters turned around within a week, I assure you that is rare!

Faculty members, don’t think you’re getting away without some advice as well.  Thoughts for you, from someone who reads many letters every year:

  • Please be very specific about how long and in what capacity you worked with the student in the clinical arena.  It helps if I know that they worked one-on-one with you every day for three weeks and that they had the opportunity to first assist with you in the OR; that letter provides me with far more meaningful information than one about a student who came to your clinic for two afternoons.
  • A comparator can be helpful.  Is this the best student you worked with this year?  In the last 5 years?  In the last 10 years?  Having a benchmark like this, recognizing that it is something you have constructed, can still be very helpful.
  • Is this student someone who you want as a resident?  If yes, say so!  If no, navigate this wisely (“I anticipate that Bob will excel in surgical residency and have a great career in academic surgery.” tells me that you think Bob is a great guy who will succeed, but he’s not necessarily the guy you always want on your team).
  • Don’t lie to try to “help” your student in the process.  When you do that and we get a resident who can’t perform anything like the student you described to us, you lose credibility.  In other words, don’t help the one at the expense of all of the future ones.  There are individuals whose letters I skip completely based upon historical experiences with people they recommended.  This also means that when you see me three weeks after Match Day, I do not want to hear, “Sally may struggle with you all…” after you wrote her a glowing, flawless letter.  Again, credibility.
  • If your student really is a superstar and has a blemish on his or her record, your letter can help me get your perspective on why we shouldn’t be worried about it as a long-term issue for them.  I don’t expect you to violate confidentiality, but it’s one way you can support a student who may have had a personal or professional rough spell and subsequently pulled it together to excel.

If you have other tips about LORs, I hope you’ll share them in the comments (or, of course, on Twitter!).

 

 

 

Good job, buddy!

As promised in last week’s great reveal about our lack of faculty-led didactics this year (thanks to all who have sent comments/ encouragement/ not thrown rocks at me), I’m absolutely convinced that one of the keys to making this transition effective lies in meaningful feedback.  Those who have worked with me know that today’s blog title is my running joke about meaningless feedback- that actually isn’t feedback at all, but is a global evaluation.

I recently came across the first concise definition of feedback that I’ve found that helps to operationalize the concept.  Feedback is, quite simply, “information about how we are doing in our efforts to reach a goal.”  It’s important to realize that it can be any information, sometimes subtle and sometimes deliberate.  What is feedback not?

-It is not advice (“Next time I would put less text on your slides.”)

-It is not an expression of preference or enthusiasm (“I LOVE your goals for yourself!”)

(Note:  Both of these examples of “not feedback” are items I am commonly guilty of with mini-clinical path correlation evaluations and with student written assignments.)

John Hattie, an Australian educator, provides a brilliant response to the question, “How can teachers learn to give and receive feedback in an appropriate and timely manner?”  His response has two key points.  First, think about feedback that is received, not the feedback that is given.  What message did your learner take away?  And second, feedback must include a “next steps” phase for the learners- his summary is that students want feedback “just for them, just in time, and with just a nudge forward.”

Grant Wiggins provides a more comprehensive list of the seven features of effective feedback.  This list includes the following (please see his original for more detail on each):

  • Goal-referenced
  • Tangible and transparent
  • Actionable
  • User-friendly
  • Timely
  • Ongoing/ dynamic
  • Consistent

If you look at the theme that underlies these features, they are all associated with achieving progress towards a goal.  Again, that idea of having the end in mind is what we need in order to know how to help people get there.  I short, feedback provides an ongoing means of formative assessment.

A paradigm I hope to play with a bit more as I work to refine my own feedback skills is the RISE model of feedback.  Most of you know that I am drawn to visual things, and this one allows students to push themselves and each other.  Perhaps we’ll see the RISE turn into the peer evaluation framework for the mini-clinical path correlations?

Now, to improve my comments above…

-“Next time I would put less text on your slides.  It can be hard for your audience to read all of it, and it distracts them from listening to you as you discuss the most important points.”

-“I LOVE your goals for yourself!  Sitting in on three family meetings and debriefing with the faculty and the family afterwards is easily actionable during your clerkship time and will expand your understanding of both perspectives.”

(And if you’re on service with me right now, get ready.  Tomorrow’s “What if?” involves me asking for your learning goal for the rest of the week!)

 

#DearIntern

Last week I crowdsourced on Twitter, asking folks for their best advice they would give a new intern.  We started out using our “usual” #SurgTweeting hashtag that a group of us tend to use for education-related surgery issues, and by the end of the week I changed it over to #dearintern.  The responses have been inspiring, funny, thoughtful…essentially everything that I expect of my Twitter community.

Read.  Enjoy. Add your own thoughts here in the comments or on Twitter if you hang out there.  I think we would all love to read them.

 

Trust me…I’m a professional

professionalism (noun):  the skill, good judgement, and polite behavior that is expected from a person who is trained to do a job well.

I’m the first to admit that when the ACGME included professionalism as one of the Core Competencies in 1999 that I immediately used the analogy to the 1964 Potter Stewart/ Supreme Court definition of pornography- “I know it when I see it.”  Of note, Stewart subsequently recanted his subjective view of the topic, and while I hold that it’s a terribly difficult thing to objectively evaluate in medicine, I don’t dispute the importance of doing so.

Professionalism in medicine has long been part of the “hidden curriculum,” in which trainees are not formally taught, but instead acquire knowledge, skills and attitudes through observation and experience.  The guiding assumption was that the mentors/ teachers were masters of professionalism, and therefore it would trickle down to our trainees.  Instead, what we have found (particularly with current generational changes) is that our trainees are often questioning our professionalism; they do want us to be good role models for them, certainly, but they’re also willing to ask why people who aren’t always succeeding in terms of their professionalism are allowed to criticize them for a lack of it.  It’s an interesting conundrum we’ve found ourselves in, really.

In 2002, the ABIM created a Medical Professionalism charter (surgeons:  please note that the ABS and the ACS have endorsed this charter).  While all 10 of the commitments are important, the one most of interest to me- professionally and academically– is the last:  professional responsibility.  This sentence states succinctly where I see us falling short:

“As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards.”

We know, from my work and that of others, that as surgeons we are not always respectful, and that some of us are downright disruptive in our actions.  I honestly believe that those who behave badly do have their patients’ best interests at heart, but simply have a warped view of how to act on their behalf.  While I don’t believe for a minute that anyone is disruptive simply for the sake of being disruptive, I do believe that we don’t act enough in a collegial fashion to help our colleagues who struggle with this behavior.  How do we create an environment that has zero-tolerance for being a jerk?  How do we create an environment in which “inciting events” are vanishingly rare, and in which the team and the surgeon have default ways to deal effectively and constructively with those events?  And how do we “fix” our colleagues who may have a bit of a predisposition to bad behavior, but don’t have a personality disorder underlying their actions?  In short, how do we do a better job being “our Brother’s/ Sister’s keeper”?

I’m working on the answers to these questions, and I hope I’ll eventually have something scholarly and wise to offer.  In my new role as Vice Chair of Education and Professionalism (I believe these things to be inextricably linked…more on that another day), I’m creating a Council with broad representation from the preoperative environment to decide how we can better define professionalism, how we can best reward those who do it well, and how we can support those for whom it’s not innate.  It’s time for us to have a not-so-hidden curriculum, and it’s time for us to step up and be the role models that our trainees desperately want and deserve.