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.

Game. Set. MATCH!

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“The last class of 48”- TAMUHSC MD grads, 1998

 

Here in the U.S. it’s Match Day, that annual event when students find out where they’re headed this summer for the next stage of their training.

Envelope

The envelope, please!

For some of us, it seems we find out where we’re headed for more years than that.  When I opened that fateful envelope in 1998, I knew I was coming to Utah for 6 years for my general surgery training.  I honestly thought once I was done with that + fellowship that I would land back in Texas.  Some 18 years later, here I still am (admittedly with that one year back in Texas for fellowship).

For me, this is a day to look forward to the new family members who will join us this summer.  It’s also a day to reflect on adventures, unexpected roads taken, and remembering just how far I’ve come in these 18 years.  It’s been a wicked twisted road, and I wouldn’t trade most of it.

 

So if you’re matching today? Buckle up and hold on.  It may be bumpy sometimes, and it will all be okay.

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.

Shame on you. Or perhaps shame on me?

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

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

Yes, shame.

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

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

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

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

Do we need a crisis management team?

(HT for this post to Amir Ghaferi, who shared a comment about teaching awards being incompatible with tenure in a clinical department earlier in the week. I assured him, and assure you, that they are not.)

I’m the first person to admit that we’re headed into a crisis in medical education, and it’s coming from a variety of sources.

  • This coming year’s statistics indicate that we will graduate more medical students than there are residency slots in the U.S.; while medical schools have heeded the call to expand to face a looming physician shortage, expansion of residency slots has not kept pace, largely because of how residency is funded.
  • The distribution of funds for residency slots has been tied to Medicare, and the 1997 Balanced Budget Act basically froze the number of residency slots.  There are interesting geographic maldistributions that are historical holdovers from I-don’t-know-what, as evidenced by New York state having just over 6% of the country’s population but receiving 20% of US funds for residency training.
  • The mission of academic health science centers has changed tremendously.  Teaching hospitals were historically just that- teaching hospitals.  No longer.  Most teaching hospitals are now part of an academic-industrial complex in pursuit of NIH funding, corporate and foundation sponsorship, and faculty are held to the fire of meeting economic benchmarks using the ubiquitous, “No mission, no margin.”  While education is still part of the mission of the academic center, it is just that…a part.  And while historical acknowledgement exists of the “academic triple threat” (remarkable clinician, feted educator, extramurally funded researcher), I’ve seen greater than one obituary to these individuals being a historical footnote in academic medicine.

For a slightly longer weekend longer read, I recommend this discussion of Ken Ludmerer’s new book on the demise of GME.  It’s worthwhile to set the stage if you don’t have an existing relationship with medical training, and it’s meaningful if you do.  While it airs many of our systemic failures in the training of young physicians, these closing lines give me hope:

“If we can restore protected time for good teaching and good patient care, they will flourish. ”

Indeed, they will, and both go hand-in-hand.

Teaching clinical skills

This afternoon my colleague Dan Vargo and I gave a session on teaching clinical skills, something that all of us struggle with in one way or another.  As much time and energy as I have invested in trying to optimize my clinical teaching, I continue to feel like I’m constantly learning new things (and, like everyone else, struggling with implementation because of the same pressure we all feel…time).

I honestly spend very little time in clinic, and when I have students with me it’s usually for the “Gee whiz!” of seeing how telemedicine works for us.  Therefore, the preponderance of my time is spent teaching in the ICU/ wards and in the OR.  OR teaching is, of course, a unique animal, and it’s one where there is still lots of space for scholarly investigation.  Therefore, I chose to teach about ward teaching, something that proved fruitful on rounds yesterday.

While Dan’s and my slides are below, here are a few things I’m looking at adding and starting to do on rounds to make them less haphazard, more planned for learning:

  • Set specific learning goals prior to work rounds, which may give learners a role that forces them to “play up”
    • “Today it is your responsibility to write all of the medication orders on rounds.”  (for an MS4)
    • “Tomorrow will be your day to take us through the examination of your patients’ wounds on rounds.” (for an intern)
    • “Friday will be chest radiograph day.  You need to be ready to read all of the chest X-rays on rounds.” (for an MS3)
  • Use a scribe or “sticky notes”
    • Assign a team member to write down a list of clinical questions that crop up during rounds
    • Keep a “sticky note” (paper or electronic) during rounds
    • Use these scribed notes or sticky notes to identify and follow-up on a couple of key clinical learning areas.
      • Real-World Example:  Metabolic manipulation in burn patients came up on ICU work rounds yesterday; we will be discussing this in more depth Monday morning during Professor Rounds, once the team has time to read up (more on this momentarily).
  • Paper rounds, or case-based learning
    • This one differs because it removes the learning entirely from work rounds
    • Key learning cases are identified in advance the discussed in a classroom/ team room setting.
    • All data relevant to the patient’s course should be accessible
    • Any aspect of their care is fair game for in-depth discussion
      • Real-World Example:  As part of our collaborative with the Department of Geriatrics, we have once-a-month geriatrics teaching rounds.  A geriatric patient’s injury and course are presented to the geriatrics faculty attending, then we have a discussion about some aspect relevant to the care of the geriatric burn patient.  Today the discussion focused on pain control.
  • Scheduled bedside teaching sessions
    • Again, completely removed from work rounds
    • A group of learners goes to the patient bedside and has a discussion about the clinical skill or clinical knowledge piece of interest.
    • Remember that the patient can (and should) be part of the teaching team here!
      • Real-World Example:  I mentioned above the plan to discuss metabolic manipulation in burns at Professor Rounds on Monday.  Our Professor Rounds involve attending surgeon identification of one patient to discuss.  We go to that patient’s bedside/ room, walk through their course briefly, then have a detailed discussion of the identified teaching topic.
  • Opportunistic (“on the fly”) teaching
    • Challenge is urgency, lack of ability to prepare
    • Solution is to have some consistent themes that arise and a “teaching script” to take advantage of these more urgent teachable moments when they arise
      • Real-World Example:  I try diligently to review depth and extent of burn wounds at the time of admission or consultation with students or residents who are present.  Granted, if it’s 2 am and the 3rd admission of the night I may do this less well.  But it is still a fairly scripted activity that I can and do walk through at almost any time.

Here’s my challenge for you:  Identify a clinical skill that you teach routinely, or a place where you could be teaching more but you’re not routinely taking advantage of the setting.  Script yourself or your activity, then try to start doing it every single time. It’s amazing how easy it becomes and how it incorporates seamlessly into your workflow.

Anyone else have wisdom/ thoughts/ ideas to share?  If so, please comment (or Tweet!).  This is some of the most important stuff that we do, and it deserves some serious reflection.

 

Behavioral feedback in medical education

Yesterday I co-moderated a workshop on behavioral feedback with Jane Dyer, one of our excellent midwifery faculty in the College of Nursing.  It’s pretty heavy on images and not text, but I think you can get the main idea of what I had to say- hopefully it will benefit anyone who is a teacher and provides feedback.

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Medical students and mistreatment

“Mistreatment either intentional or unintentional occurs when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process. Examples of mistreatment include sexual harassment; discrimination or harassment based on race, religion, ethnicity, gender, or sexual orientation; humiliation; psychological or physical punishment; and the use of grading and other forms of assessment in a punitive manner.”- AAMC definition of student mistreatment

One of the eternal challenges presented to clerkship directors, particularly in specialties with lesser reputations for begin “kind and gentle,” is trying to mitigate medical student mistreatment.  Although administrators  (the Deanery, as I refer to them) and those of us in the trenches have made almost heroic efforts, reports of mistreatment from students persist.  The 2012 AAMC Graduation Questionnaire shows at least one incident of mistreatment during their training by 47% of students; public humiliation was indicated by 34% of students.  Variability in rates occurs between institutions, as does variability in cultural expectations- which may in turn effect rates.

One of the real challenges in reporting and addressing mistreatment lies in the variability of definitions.  Excellent work published earlier this Spring in Academic Medicine used grounded theory methods to develop this concept map of student mistreatment when placed within the context of suboptimal learning environments.  I would argue for most of us who are dedicated to fostering positive learning experiences, the second type (environment-based) is the most prevalent, the most insidious, and the most challenging to address.  While incident-based episodes are generally within the framework of broader professionalism issues and effective interventions have been identified, the cultural issues are more deep-seated and may be indicative of institutionalized unconscious bias.  Lingering mistreatment in an institution dedicated to its eradication implies the importance of culture and bias.

My fundamental worry on this issue isn’t that I am concerned about reporting, or even about mistreatment for its own sake.  My concern is the known relationship shown between mistreatment and suboptimal learning environments; the truth is that when learners feel threatened, they develop the phenomenon of “lizard brain.”  Lizard brain may do great things for our survival, but it certainly doesn’t foster a supportive and creative learning environment.  Most dangerously, it doesn’t train our learners to be problem-solving physicians when we make them question their own value in every single clinical decision- and we’re really not helping them establish the confidence in their skills and knowledge to make the right decisions when the chips are down.

I’m not sure I have any great wisdom or solutions.  Yes, we need zero-tolerance policies for mistreatment- and for disruptive/ unprofessional behaviors in general. Yes, we need anonymous reporting with investigators who are seen as impartial by those on both sides of the power divide.  And yes, while my primary commitment is to the students, we must acknowledge that mistreatment of anyone in a professional environment simply is not okay.

Or as succinctly stated by another author in the title of his piece on this topic, “Why can’t we just be nice?”

 

Medical students and basic skills acquisition

The world of medical education is becoming progressively more structured, particularly with an eye to standardization of curricula, and a great deal of this is being done in the name of patient safety.  I’m going to preface the rest of this post with an acknowledgement that I believe that it is important for our students to graduate with their MD with a certain basic and essentially universal skill set, and that they should learn to do that in a way that will not harm patients.  This is why simulation has become a core feature of medical education, and why I’ve had to learn to embrace it, as someone who came into education from the assessment and curriculum side.  However, sometimes good intentions can get in the way of medical education, and that seems to be happening to my students right now.

Let’s use Foley catheter placement as an example of the larger question at hand here, though it could apply to many basic technical skills.  All hospitals have a tremendous focus on CAUTI elimination in this day and age, which is appropriate.  However, many hospitals have placed a moratorium on medical students placing Foley catheters because administrators believe that students are by definition a risk factor for a CAUTI (Note:  NO literature supports this assertion.  None.) However, it’s not simply my expectation but that of the American College of Surgeons that entering interns know how to insert and maintain a Foley catheter.  This isn’t “just” a surgeon issue either; in fact, the core medicine clerkship guide published by what is now the Alliance for Academic Internal Medicine indicates that Foley catheterization is a core skill that should be demonstrated during the internal medicine clerkship (p.80-81).

Clearly there is an expectation that students learn how to place Foley catheters, but it’s not clear when and where they are truly learning this skill.  A recent survey of members of the Association for Surgical Education about basic technical skills had some fascinating findings, one of which included the teaching of Foley catheterization.  68% of respondents thought that Foley insertion was being taught as part of a course at their institution, while 18% did not think it was and 15% weren’t sure.  In terms of when Foley insertion was being taught, 41% thought before the surgery clerkship, 28% thought on the surgery clerkship but before the OR, and 19% thought it was being taught “on the fly.”  This single set of results highlights two big problems- one, that no one actually seems to know when and how basic skills acquisition is happening, and two, that there is still a culture of basic skills being taught in real time when simulation is readily accessible for these skills.  Stay tuned for more on this topic; we’re working on the manuscript.

With regard to the question about students increasing the risk of CAUTI, there is evidence to the contrary- at least in the face of a structured training paradigm.  A few years ago UPenn found itself in a similar situation to the one I currently face, in which their students were not being allowed to place Foleys because of concern about CAUTIs.  Rachel Kelz and her team initiated a credentialing program for the students as part of the surgical clerkship that is quite similar to the current checklist we use at Utah.  The findings from their study showed that Foleys inserted by credentialed medical students had a CAUTI rate that could not be differentiated from non-medical student inserted Foleys. I was asked to write a commentary on their manuscript, and in it I noted that structured training paradigms for skills are to the benefit of both our learners and our patients.

So, yes, I am on board for the idea that the students should be formally trained before we allow them to insert a Foley catheter- or place an IV or suture a laceration.  As medical educators and advocates for the care of our patients, it’s simply the right thing to do.  However, if my students are formally trained via simulation and have been “credentialed,” it’s important that they get this opportunity.  I hope that administrators everywhere can come to understand that.

 

Matchmaker, matchmaker, make me a match

It’s that day, if you’re in medical education.

Really, it’s the whole week.  Monday is the “big” hurdle, when those students who have successfully matched into residency can stop worrying if they matched and can move on to worrying about where they matched.  Monday is also the day when students who did not match get very busy for a couple of days as part of the SOAP (Supplemental Offer & Acceptance Program), seeking an unfilled spot that will meet their educational and professional needs.

Admittedly it’s been a few years since my Match Day but I still remember it quite clearly.  There was a huge sense of relief about finally knowing where I would be headed in June; I had known for months that I wasn’t staying in Central Texas, though I had no idea of the long-term implications of matching at Utah for my career.  16 years later, here I am, still in Salt Lake (albeit with that year I went back for fellowship in Texas as part of the equation). Subsequent match days have been filled with excitement from seeing who would be following me in the residency program, then who would be “my” residents once I became faculty.  As I’ve become increasingly involved with the medical students over the last 5 years, it’s become a day of pride and celebration as I see where students whom I have mentored find out what the next chapter in their professional lives will be.

Understanding the match process can be a little complicated.  Essentially, students apply for residency interviews.  After the interview season is complete, the student and the interviewing programs each make a rank list in order of preference.  A computer then runs an exceptionally complicated algorithm (and one that favors the students over the programs, appropriately) and voila- matches are made.  If it tells you anything at all, the economists who designed the Match algorithm won the Nobel Prize in 2012.  Generally speaking, the system works and works well.

So, today.  Match Day 2014.  Approximately 17,500 senior medical students in the U.S. will find out where they’ll be in 3 short months on the next part of their journey as a physician.  To those of you whom I know…and those whom I don’t…wishing you good luck today that you land in a place that will be just right for you.