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.

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.

 

Don’t be cruel

While none of us are eager to admit it, many of us have witnessed bullying in the healthcare environment. Sometimes it’s senior physician versus junior physician or medical student. Sometimes it’s physician versus nurse. Almost invariably it involved the presence of a power differential, someone who is advantaged versus someone who is not.

This past week, this podcast was released as part of the JAMA Podcast series.  If you’re not familiar with the JAMA Podcasts, they are pretty terrific.  In this one, Ed Livingston cites much of the data about the prevalence and impact of abuse/ bullying, with a particular focus in this podcast on medical students. If you want background reading for the podcast, the original case and discussion are here.  I want to highlight the importance of ignoring behavior like that described in the podcast (as do Dr. Lucey and Dr. Livingston)- if we ignore this behavior, we’re implying that this is okay.  Note: I am particularly heartbroken by the surgeons who were so terrible to the medical student- I promise we don’t eat our young. Also, if you’re in training as a student or resident and have someone in a position of power who is bullying you, it’s likely not just you they are picking on…find someone safe to report it to who can hold them accountable.

Interesting timing of course means that during the same week something came across my email talking about how to overcome bullies at work.  An important point that he makes is at the very end: If you’re surrounded with jerks, you’re at higher risk to become one.  Choose your environment wisely. (((Related but unrelated: some of you have heard me talk about Eric Barker’s blog in the past, and this piece is no exception to his usual brilliance.  I try to subscribe wisely to things, and his weekly blog is a highlight in my email inbox on Sundays.)))

And what if this isn’t about a power differential, but is more about a peer who is a jerk when they aren’t being watched? Remember not to get hooked, and that it’s really not about you.  Then refer back to the prior piece.

 

 

 

 

…and doggone it, people like me

Many of us remember laughing at Al Franken’s Stuart Smalley character on Saturday Night Live; for those who don’t remember the skit, the character is focused on repeating positive affirmations (and it’s still worth a watch).

I’m currently reading Appreciative Leadership, which I’ve am convinced may be the best leadership book I’ve read ever. The authors provide a framework for using appreciative inquiry as an approach to leadership.  The framework uses five “Is” for appreciative leadership: inquiry, illumination, inclusion, inspiration, and integrity. As I read the chapter on Illumination, I’ll admit I giggled thinking about a Stuart Smalley skit for a moment, then realized the actual value of positive self talk for generating what the authors call “positive power.”

If you think about when you’re at your absolute best, what thoughts are you having about yourself? Chances are that this is not when the word “loser” comes through your mind repeatedly, or when you’re wrestling with a case of impostor syndrome. Now, if you extend this to your team, what thoughts do you have when your team is performing at a crazy-amazing level? Again, I doubt that you’re thinking about how tired you are of Bob and Betty fighting, or what a poor lead nurse Billie Jo is.

Admit it- when you recall situations in which there was great success, you tend to go positive with the things you think about.  It immediately tells you what your and your team’s strengths are, and it gives you confidence to perform at a high level.

Time for a confessional: As I thought about using strengths and success oriented self-talk, I had a moment of self-illumination.  I realized that during the times when I have not been a good leader, when I’ve been petty and difficult, it has uniformly come from a place of insecurity. And what’s put me there? That little voice telling me that I’m not enough, that I don’t belong there, that I really can’t do this.

Additional confession, or wisdom grown from my own lack of it: If I’ve learned any lessons in the last decade, one of the biggest ones is that people “feel” that insecurity and that sort of inner monologue.  They know you’ve got doubts, and if you’re supposed to be leading them they’ll start to doubt themselves and the team too.  It becomes a vicious cycle.

That leader stands in stark contrast to the “I’ve got this, and we’ve got this” leader who instills confidence in the team, makes them more capable, and helps them to achieve at a higher level.

Which leader do you want to be? And what are you telling yourself about your ability to be that leader?

 

Second-hand stress

The day of a highly contentious national election seems like the fitting time to talk about responding to stress in our environments.  In truth, I probably should have put this together months ago (because the campaign has been all sorts of fun, right?), and instead I’ll declare it a “better late than never.”  It’s not like stress is going away from any of our lives anytime soon either, if we’re completely honest.

If you think Facebook, Twitter, and listening to the news have all been stressing you out for the last few weeks, you’re completely right. Being around people who are stressed can stress us, even when it’s just observing that stress electronically. We’re perceiving threats and we go into fight or flight mode, even when the stakes don’t involve immediate survival.

Fortunately, HBR has a publication on making yourself immune to secondhand stress (as well as a one minute video if you don’t want to read today). To summarize their tips and tricks, here they are:

  • Change your mind– What I really mean here is to change your mindset.  If something is bothering you, you either need to change it or change how you are viewing it.  Complaining benefits no one, and if anything it scares people off because you get seen as being a “negative Ned.”  Don’t be that guy.
  • Create positive responses to stresses when they happen– Someone glaring in a meeting? Smile at them (no, really, do it!  It’s fun!). Lead your conversations with others in a positive way (“How can I help you today?”) versus a negative opener (“I’m way too busy for this right now.”). What kind word or show of patience can you provide today?  This is NOT hard, it does not cost money, and it makes you feel great.  Try it!
  • Build your copamine- You can handle these bad days.  You CAN.  The proof lies in the fact that you’ve survived all of the prior bad days. And if that reminder isn’t enough for you, why don’t you go for a walk/ run/ swim/ bike ride/ dogwalk/ yoga practice?
  • Practice positive habits– It’s not just about these habits being “good” habits; they are habits that when built make you more positive.  Want to know what they are?  Here’s a TED talk to help you learn.  Oh, and if you need a mediation resource, check out Headspace, and not just for Andy’s awesome accent.

Feel free to use any of these tricks today for the election, tomorrow at work, or any time that you realize you want to be in a better space.  Do not let the world get you down!

Shame, patients, and the Internet

“If we can share our story with someone who responds with empathy and understanding, shame can’t survive.”- Brené Brown

Last week over lunch, a colleague and I were discussing some of the on-line physician groups that are out there.  Some are on-line communities within organizations, others are Facebook groups. While we both acknowledged that some of those groups can be incredibly helpful for building a community around shared experiences in the challenges of our work, she astutely noted something troubling to her, and that I realized had been an intangible quality that had troubled me more than once.

It’s the fact that within that “safe” space there seems to be this more-than-casual practice of patient-shaming (Note: It’s the Internet, people. Nothing is “safe” if someone gets a screen shot.). It’s the discussion the obese patient, or the patient whose lifestyle choices we disagree with, or the patient who keeps turning up in our clinic with injuries from self-harming in a way that judges them.

As physicians we’re known to sometimes do this in person, and it seems to be we’re more likely to do it to women (yes, there’s both anecdote and science supporting that claim).  But the internet, particularly these spaces in which we’re with our own people, provides a whole new area of questions around how we talk about our patients.

I’ve heard the argument that it’s like being in the physician’s lounge to talk about patients in this sort of space. I would argue it’s nothing like that, mostly because we don’t have direct personal relationships with most of the individuals in those communities and you don’t know if someone caught a screen shot of something posted that crossed a line. It would be horrifying to post something, realize later it wasn’t a good idea, go back and take it down, and only have it come back to haunt you later because of the dreaded posterity of the internet.

I get that we’re tired, that many of us are struggling with burnout, and that we need some sort of way to process dealing with patients who challenge us.  I’m not saying that I haven’t (under a cone of silence in a true safe space) expressed frustration with a patient and/ or their family; if you haven’t EVER done that, you’re a better person than most of us in healthcare, and we also want to know where you acquired your collection of perfect patients. What I am saying is that we have an obligation as leaders and as human beings to think carefully about the reprecussions of things we say and things we write. More importantly, even when we’re tired and cranky and just DONE, that’s the time we need most to call on our compassion and remember why we chose this profession in the first place. And, of course, we need to choose our audience very carefully when we really just need to vent- and we need to stay out of judgment when we do.

Before you post that patient story in a community or group, think about how you would feel if you knew that you or someone dear to you were being written about in the way you intend to tell the story.  If the answer is either “not very good” or “I’d be furious”, it’s wise to reconsider your decision. And if you see or hear something that makes you uncomfortable, I would encourage you to let the author know that it does and why. We need to learn from one another, and we need to encourage one another to be our very best selves.

 

Rites of initiation

“I’m not sure why they even gave you a spot in the medical school class.  That was a waste.”

Since it’s the third Tuesday of the month, that also makes it time for Schwartz Rounds at the University of Utah. Today was a topic that ties back to my research and informs the culture that I strive for us to create in healthcare- hazing in the healthcare hierarchy.

Mistreatment is something that is real within the educational process, particularly for young physicians, because of the hierarchies that exist in healthcare.  While the language that is most often used is that of mistreatment, use of the word “hazing” paints a more dramatic but no less accurate picture of what happens when these power inequities are abused.

Overheard at the nursing station: “You must be the stupidest intern ever!” 

Hazing Is: “Any activity expected of someone joining or participating in a group that humiliates, degrades, abuses, or endangers them regardless of a person’s willingness to participate.” I’ll grant that in the healthcare context we’re not talking about making someone drink themselves into oblivion or get their pledge signature book filled, but if we embrace the idea that hazing involves disrespect, that it infringes upon personal safety (physical or emotional), and that it fails to serve the purpose of the greater organization, we can all probably think of some examples from our workplace.  And when we put those into the context of how harshly we judge fraternities, sororities, or athletic organizations that haze, we get uncomfortable quite quickly.

Most hazing behaviors in healthcare- or mistreatment if that makes you less squeamish- are a historical holdover. “Well, it happened to me and I’m a better doctor for it, so it’s okay” is a statement I’ve heard more than once from a resident or student who experienced verbal abuse from a faculty member.  While it may be true that they did learn something from a public berating, the reality is that it’s unlikely to be durable learning because it preyed on their sense of shame (unhealthy motivator) rather than a sense of guilt (healthy motivator). Until we both name it and stop excusing it- and recognizing that it is NOT harmless to our trainees’ mental health- hazing is not going to slink off into the dark where it belongs. Let me clarify my point: It is NOT okay.  End of discussion.

I’m too busy to teach you today in clinic.  Can you just go get us all some coffee?

One of the reasons that hazing happens is based upon an idea of weeding out the weak. If you work in medicine, regardless of your team role, you already know two things for sure:

  1. Medicine is hard. We all do lots of hard things every day. We don’t need to make it harder.
  2. Entering a career in medicine already has a high bar, and if someone is truly “weak” they’ve already been culled.  Yes, there are people who are a poor fit for certain specialties; the likelihood that they are weak and need to be taken out of the herd entirely is inordinately low.  It’s also not one individual person’s decision to make.

I trained in a time (pre-workhour restrictions) and in a specialty (surgery) that weren’t known for kindness. In spite of that, I can’t look back at my training and call it malignant.  I’ll confess that as a 2nd year resident I was found crying in the corner of the SICU one day, and when the pharmacist who found me in that condition asked me what was wrong my answer was simply, “I’m tired of people being mean.” I’m also certain that in the sleep-deprived state of some of my training years there were days when I was one of those mean people (and if you were on the receiving end, I am still truly sorry for that). Overall, though? I was generally treated well by people even if the system wasn’t designed around kindness.

I’m fortunate to be at a point in my life where it’s a priority to me to lead within a culture that doesn’t tolerate meanness/ mistreatment/ hazing for its own sake. The negative things that happened to me weren’t necessarily right, and it’s my responsibility to not pay them forward. We all owe kindness and respect to one another as humans who are being.

“You seem like you’re struggling right now.  Let’s find some time to talk about it so I can figure out how to best help you.”

Yes.  That’s better, isn’t it?

Do you hear what I hear?

Listen.

What do you hear around you right now?

I’m standing in the Sky Club in Atlanta on a day of complete travel meltdown for Delta, and here’s what I hear around me right now:

  • Some dude-bro behind me on the phone having a conversation I don’t understand most of.  Yes, it’s in English.  Sort of.
  • A low-level cacophony of other voices from all over the room.
  • A three year old telling an awesome story to her Mom.
  • Ice being scooped into glasses at the bar.  Glasses clattering.
  • Flip flops and luggage wheels of someone walking by.
  • Jet engines.
  • Laughing teenage girls over in the corner (see, the flight delays are fun for SOMEONE!).
  • Rustling of papers.
  • Clicking of the keys on my computer keyboard.
  • The “meep” of desk agents checking people in.

I try to do something like this as an exercise at least once a day by really focusing on all of the sounds that I hear around me. It’s often something I do in the mornings when I’m out walking with Olivia, and I do consider it a form of meditation to just focus on all of the sounds that are there.  It forces me to really, deeply listen to what is going on around me.

It’s want to believe that deep listening in my environment is transferrable to those times when I need to have serious conversations, be it with colleagues or with patients and families. It forces me to focus on that one sense and on the things that are around me, and when I’m in a quiet room with one or two other people, it allows me to move past all of the possible distractions that are out there.

We all have heard so much advice about how to be a great listener (in the interpersonal sense), and a recent HBR article indicates that pretty much everything that we’ve all learned is just plain WRONG.  Good listening involves asking critical questions, building self-esteem, having give and take, and making meaningful suggestions.  That idea that you get to passively nod and smile and be considered a good listener?  Nope.  It’s not that at all.  It’s much, much more challenging than that because it requires not just listening but communicating effectively.

One of the aspects of the article that I particularly appreciated was the idea of levels of proficiency in listening. Since we all almost certainly overestimate how good of a listener we are, the levels in the article give us a guide for our listening aspirations.

And perhaps the one piece of advice for Level 6 is the most important part of being a good listener- it is NOT about you.  Easy to say, and again, hard to do.

I challenge you to listen differently this week in just one little way.  Maybe it’s ignoring your phone while you’re in a meeting or having coffee. Maybe it’s staying curious about something you are being told and being brave enough to ask a question. Maybe it really is “just” listening and expressing support for someone in a challenge they want to take on.

And that listening exercise we started with?  Highly recommended. It can be fascinating.

Words, words, mere words

This link describing the difference in language in performance reviews of men and women came across my Facebook and Twitter feeds.  To summarize the HBR piece it draws from in one sentence, men are more likely to get specific information about what they are doing well and what they need to do to get to the next level than are women.

Men get feedback on technical aspects of their performance. Women get feedback on their communication style (when is the last time you heard of a man being described as “aggressive” in an evaluation?). Men get constructive suggestions.  Women get constructive suggestions and are counseled in effect to sit still and look pretty. Men are acknowledged for their individual results.  Women are described for their team accomplishments. Men are expected to be independent and self-confident.  Women are criticized if they aren’t collaborative and supportive.

The real issue with the implicit bias that appears to pervade evaluation in so many areas of business and tech is the impact it has on women’s professional development. Although little work has been done to date, I suspect that the same phenomena are at work for medical students, residents, and women in academic medicine.

And, of course, since I always try to bring solutions for the problems I share, I’m particularly fond of solutions modeled on those recommended in the HBR article. For those of us in roles of evaluating our learners and our peers, how can we best do this to mitigate the unconscious bias?

  • Use specific criteria (or anchors) to evaluate individuals. What does competence look like for a specific skill or activity? What does mastery look like?
  • Set three measurable outcomes to review for each individual.  These may vary from one to another (no two individuals are alike); the key is that they should be measurable.
  • Relate feedback to goals or outcomes. Instead of saying, “Great job during that OR case!” perhaps we should mention to the resident, “The time you spent getting good exposure of the trachea made the actual placement of the tracheostomy safer for the patient and technically easier for you.” Or instead of saying, “The whole room thought you were panicky during that trauma activation on a patient who was clinically stable,” we could say, “We should work together on you maintaining command of the room during low-level trauma activations so that you can do the same when we have unstable patients. When you seem anxious, the team picks up on that and it impacts their care of the patient.”
  • Written reviews should all be of similar length- which also means similar level of detail.

I know that I’m discussing these issues largely in broad strokes. I’m also not finger-pointing at anyone in particular, especially because it appears that women bosses and men bosses are equally guilty in the business world. I’m also curious to look at evaluations I’ve written over the last couple of years on students and residents to see if I’m guilty. If I manage to pause and adapt a comment I might make tomorrow morning during our residency review meeting, it’s a victory for me and for that learner.

Most importantly, I want to put this in front of you, my readers, because the best way to beat unconscious bias is to realize that it exists.

 

The Buddha Walks into the OR Part 5: Attention, Please!

It’s almost impossible to look around and not find something in media, in pop culture, in all sorts of places about mindfulness.  Interestingly, it’s not just out there in popular culture; my friend and fellow burn surgeon Sharmila Dissanaike led a session during last year’s American College of Surgeons Clinical Congress on mindfulness.  One of the ways in which she highlights the relevance of mindfulness is around resilience, which we know helps to protect us from burnout and career dissatisfaction.  In short, she sees mindfulness as a tool to expand our resilience and help us maintain our passion for our careers.

Mindfulness is also the 5th Paramita, or perfection.  Mindfulness takes practice, and over time it does cultivate the other perfections. An important feature of mindfulness in this context is the relevance of focus, and of tuning out distractions, in a way that we can concentrate on being in this very moment. As I write this, I’m suddenly struck by the serendipity of Tuesday’s blog on multitasking and cognitive bandwidth; even though I was writing about that from a pedagogical perspective, the key message was how we can help learners gain and maintain their focus so they can be more effective.

Susan Piver discussed meditation in one of her recent Open Heart Project weekly Dharma talks as a tool to unite the first four paramitas. Generosity and Patience both come from a place of opening that requires awareness and observation. Discipline and Exertion are more pointed and fierce, and are associated most strongly with mindfulness because of that focus. By putting Discipline and Exertion to work for ourselves, we are able to open to experiences in a way that demonstrates Generosity and Patience because we have more insight.

As surgeons if we are able to be right here, in this exact moment, then we are able to be more effective in our technical and cognitive work. As people, if we are able to be right here, in this exact moment, then we are able to be more compassionate caregivers for patients and families, and we’re able to be more effective team leaders. As family members, if we are able to be right here, in this exact moment, then we are able to be a more effective mother/ father/ sibling/ child/ parent/friend.

What is in front of you right now?

How can you use this moment to both focus on and open to what is around you?

Imagine the difference that mindfulness can make in your ability to both feel good and do good.

Be here.

Pay attention.

*****
Blogger’s note: Heeding my own advice about being present and paying attention, you’ll have to wait 2 weeks for Paramita #6. It’s time for my summer break!