Today’s installment: My life as a policy wonk

Last weekend was an important weekend in Washington DC, not just because of the opening of the National Museum of African American History and Culture, but because it was the Fall meeting of the American College of Surgeons Health Policy and Advocacy Group (HPAG).  For those who aren’t familiar, the HPAG is the leadership group within the College that works on political issues on our behalf as an organization.  For years, the HPAG was incredibly focused (almost singularly so) on SGR repeal.  Now that we’ve checked that box, the HPAG has been able to move on to a broader variety of issues; some of these are around MACRA, the replacement for SGR, and many of them are not. Today’s blog mission is to let you know what our key HPAG topics were last weekend, and to start to educate my surgeons readers on those issues.

So…in agenda order…my take on our top 3 topics from theFall 2016 HPAG meeting-

GME– A small group has spent the last 9 months (oh, that timing seems appropriate!) developing a white paper on GME that can be used in discussions with members of Congress and their staff. Meaningful GME reform, as we are describing it, includes the components of workforce, finance, accountability, and governance. Within these four areas, the white paper includes the following proposed steps:

  • Workforce- support healthcare workforce data collection and research
  • Finance- maintain current levels of GME financing and appropriate temporary additional funds to support a GME modernization and quality improvement program
  • Accountability- combine DME and IME into a single stream of GME funds
  • Governance- move toward a regionalized GME governance system

While this gives you a crude outline of what the GME workforce group proposed, I hope to share more with you about this in a month or so once it is approved by the ACS Board of Regents. This is an area I’m particularly excited about because of my own roles in surgical education, and because it represents an opportunity for our profession to lead.  Change is coming to GME; this is our chance as surgeons to help define what that change looks like.

Global codes data collection– CMS has proposed onerous data collection around 10-day and 90-day global codes. The current proposal is for ALL practitioners who provide services under these codes to collect data on ALL patients served under these codes and for ALL services other than the procedure. G-codes were developed in conjunction with SAGE that require reporting of care in 10-minute increments, and using vague descriptors of “typical,” “complex,” and “critical.” The one that is most interesting to me as a burn surgeon is that “change dressings” is included as a typical visit.  Anyone who has spent any amount of time in a burn clinic knows that our dressing changes are anything but typical, and really don’t belong in the same category as a dressing change on a patient who had laparoscopic surgery.  Also, this idea of 10-minute time increment reporting strikes me as ludicrous because it is entirely inconsistent with any workflow (and quite frankly, would interfere with providing actual patient care, which is what I believe I’m supposed to be doing). The ACS is asking CMS to alter their plans to only obtain data from a representative sample of physicians and to avoid use of the unvalidated G-codes.  Again, stay tuned…I’m sure there is more to come on this, including an ask for people to reach out to their members of Congress.

MACRA and QPP and APMs and MIPS- oh my! Yes, it’s time to dig in around the alphabet soup that replaced the SGR. The most important thing for you to know are the following two things:

  1. The ACS is working to develop APMs (Alternative Payment Models) for common procedures in conjunction with Brandeis. Again, stay tuned.
  2. The ACS will have a major education campaign for us around QPP (Quality Payment Project). If you want to see the resources that are being made available, please look here. There are four things that you can do to get ready for MIPS (Merit Based Incentive Payment System)- 2016 participation in PQRS, review your quality and resource use report (QRUR) from CMS, review the clinical practice improvement activities list when it’s released in November and choose 6 for 2017, and make sure your EMR is ONC certified/ review your meaningful use data. None of these things are terribly tricky, none are designed to be terribly time-consuming.  User-friendly videos, all of which provide information in digestible bites, will be available soon to help make this process as seamless as it can be for all of us.

I want to be clear- these are not the ONLY things that HPAG and the Advocacy and Policy Division are working on.  They’re simply the three things that struck me as the most pressing, most meaningful areas that the DC office and the ACS physician leaders are addressing.

And now…back to our regularly scheduled, non policy-wonk programming.

The Buddha Walks into the OR Part 4: Exertion

In our continuing quest to bring more fierceness to our lives and how we live them, today’s blog will dig into the 4th Paramita: Exertion.

We don’t mean exertion in the sense of running 200 meter repeats in 94 degree heat, even though that’s what I did yesterday evening.

We don’t mean exertion in the sense of working yourself into a state of exhaustion, depleted of all energy.

What we do mean related to the idea of making a joyful effort. Exertion in the Buddhist sense is finding the energy to do all of the things that you do. It’s understanding what your motivation is, and using that to sustain you during those times when your energy wanes. How many of us can think of those days when it’s been a long, hectic day in clinic or in the OR that leaves you completely drained…then you find a thank you note from a patient or their family, or from a mentee? How many times has some small reminder of why we do what we do, particularly on the days it’s not easy, suddenly helped you to hang in there an hour or two longer? Suddenly we find our endurance…our sustenance…our ability to forget about how tired we are and just focus on what we’re doing right here and right now. The slog transforms into a (relatively) joyful effort, simply with one small thing that pulls us back to our purpose and back to the present.

Exertion includes the idea of persevering during failure, and viewing a failure as a step towards success. This recent publication from a Princeton professor has been met with some controversy, particularly by those who hold that you can only afford to catalog your failures if you are viewed as successful. He openly acknowledges that each and every one of his failures in academia has been a building block for his success- and perhaps that in some ways the failures have been more important than the successes. It’s an ideal example of exertion in action (and I’ll confess that I am particularly fond of his meta-failure; I related to it since my Blog is read far more than all of my academic publications combined!).

Exertion, perhaps most practically, comes back to that critical idea of managing your energy so that you can do all of the important things.

Think for a moment about things that deplete you of energy. How many of them orient around fear, doubt, anxiety, not knowing, trying to “force” things to meet expectations? I’ll admit that for me that last piece is critical- it’s often the things I feel like I should be doing to meet some external expectation (real or made up) that drain my energy the most. I’ve learned that any sentence that includes the phrase, “Well, I should…” is an indicator that danger is lurking.  Shoulding all over yourself is inherently a bad idea and if I may give you one piece of advice about this behavior, it would be to stop it.

Now think for a moment about those things that provide you with energy. Some of them are probably quiet and peaceful- laying in a hammock somewhere listening to bird calls, falling asleep in a tent next to a river, meditating. I suspect that more than a few of them are not things that are quiet and peaceful, and that some of them are in fact incredibly challenging from a mental or physical perspective.  How is your energy level at the end of a big, difficult operation when you KNOW you’ve been able to help someone? At a rock and roll show with your favorite band (I’ll humbly suggest a Jason Isbell concert as an example)? At the end of a track workout with 200 meter repeats in blistering heat with friends who make it fun, even when it’s hard (I left mine giggling last night)?

Show up. Work hard. Remember your motivation. Stay present. Mind your energy.

Or, as my favorite running tank says, “Nothing about this is easy. Everything about this is worth it.” If that’s not a phrase consistent with creating a joyful effort, I don’t know what is.

 

 

 

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.

Leading from where you are

I’ll start with a confession: I played hooky from the office for a couple of hours this morning.  No, I wasn’t out for a run or off to yoga (my usual activities when I am playing hooky), or trying to get a manuscript done without distractions.  I spent some time touring the Utah Opera Production Studios, then at a strategy meeting for Utah Symphony Healthcare Night, which is coming up in March. Some of you are also aware that I am involved with a capital campaign committee for the Alpha Delta Pi Foundation.  Most of you are well aware that at any given moment I have more than a few things going on- though I shy from the word “busy” because really, we all are busy.

I suspect that some think I’m a little crazy for taking on these additional roles that have absolutely nothing to do with my academic surgical career, and that may well be true. But I take these things on and I take them on with joy. My truth is that I have an obligation to my community, however I define that, to make it a better place. My belief is that I am incredibly fortunate to be where I am doing what I do on a daily basis (even when call induced sleep deprivation makes me super-crabby, as it may have this week). My obligation is to face the world as a leader because of all that I have both earned and been given.

IMG_2033.JPGOf awards I have received over the years, this one is quite possibly my favorite. It is named in honor of one of our faculty members who was the Founding Dean of the medical school at Texas A&M.  I spent a lot of time talking to Dr. Knight as a medical student about many, many things (the fact that he was ordained Methodist clergy particularly fascinated me since Divinity School was my back-up plan if I didn’t get into medical school) and he is someone I will always have tremendous respect for; he was a medical educator before that was “cool” and he was absolutely committed to the physician having more dimensions than a plate. His emphasis on the physician as a community leader was something that stuck with me, something I tried to do every day as a medical student, and something I continue to strive to be.

In hindsight, I realize how truly fortunate I was to have a mentor who believed so strongly in science, in compassion, and in leadership. I’m not sure that I get all of those things exactly right every single day but I do know that as a physician they define who I aspire to be.  Most importantly I hope that by modeling these qualities that I’m helping to shape the next generation of physicians- something that I know would make Dr. Knight incredibly proud of his legacy.

How are you going to be a leader today?  It doesn’t have to be anything big.  Start where you are.  And lead on!

#SurgPostIts

I’ve been posting them for about a month now, so it’s probably time for me to do some explaining about #SurgPostIts. Where did they come from? What are they? And, for the curious, why?!?

For several years I have had a life-list goal of post-it note “bombing” somewhere in my travels. The idea behind post-it bombing is to plaster a limited area with positive post-it note messages; my intention was to leave inspirational messages in my wake. But where?

Me, hard at work on the Post-Its during our Council meeting.

Me, hard at work on the Post-Its during our Council meeting.

The week before October’s Association of Women Surgeon’s meeting I realized that I had a prime opportunity to post-it bomb the entire MEETING- it’s a relatively small meeting, usually with about 150 in attendance, so it was a manageable idea.   It would mean getting some mini-post-it notes and (legibly) writing messages on them then leaving the all over the conference room. We all know that I love a challenge, even a small one, so the plan was made.

 

Choose Joy!

Chase Joy!

Saturday morning as the meeting got started, I wandered the room and left post-its at each place that was set. None of them were anything that I thought was a huge deal on their own, but what struck me the most was the number of people who told me later (when they figured the whole thing out) that the message I randomly left in their place was exactly what they needed in that moment. A resident who promptly attached it to her phone picked up this note. I was grateful that she “got it” because I do remember how hard it can be to remember your joy when you’re in the challenges of training.

You can do hard things

You can do hard things

This note was apparently perfectly timed for an attending surgeon who just moved across the country and is settling into a new academic position. I was flattered when she Tweeted that it would be the first thing to go up in her new office- and knowing her as I do, she can (and will) do hard things, and will do them gracefully.

Based upon the reactions to the post-its on that day, I started a year-long project on Twitter with #SurgPostIts. Every morning at 7 am I post a positive message (confession: yes, I am scheduling them so I don’t mess up). On Saturdays I assign “#homework” as part of the #SurgPostIts project to help keep us all grounded in the craziness of our lives. And at the behest of a good friend who is an anesthesiologist, I have now started to include the hashtag #ORPostIts. Joy shouldn’t be confined to one group, right?

I hope you’ll enjoy the #SurgPostIts, and that they will serve you on a day when you need it the most. It’s my small part in helping us all remember that we have everything we need- we just need to remember to access it.

 

 

 

No easy answers

I spent last weekend and the early portion of my week in Napa for the annual Western Surgical Association meeting.  I’ll start with the statement that this is one of my favorite meetings every year; it’s rich in high-quality general surgery research and I always get to hear interesting new findings in areas I don’t necessarily work in.  And, of course, it’s a meeting I always enjoy because of the people.  I love the fact that I get to spend time catching up with two of my mentors from medical school every year (Sam Snyder and Randy Smith).  It’s nice to know that they are still as terrific as I thought they were when I was a starry-eyed MS3/ MS4.

During the scientific sessions I Tweeted out a few key items from various papers that were presented, and one deserves further mention here, if for no other reason than to continue the dialogue it started on Monday morning.  Here’s a screen shot of the abstract in question:

Can chief residents not do open choles any more?

Can chief residents not do open choles any more?

 

Tyler Hughes, rural surgeon advocate extraordinaire- and fantastic human- addressed the elephant in the room- can someone pass their certifying exam (CE = oral boards) in general surgery in this day and age if they say they would either get an intraoperative consult from a specialist colleague or abort the case and refer a difficult cholecystectomy because they don’t know how to do them open due to lack of experience?

Or should we give a candidate credit for knowing when to call for help?

Do we need to modify our training paradigm to emphasize acquiring relevant experience, as proposed by the authors?  Is this yet another reflection of the need for us to update/ refine training for people to become a “true” general surgeon?

I look forward to a robust dialogue continuing on Twitter, on FB, and/ or on the comments here.

 

 

Unapologetic

In the heels of last week’s admonishment to not be afraid to say no, there’s really only one logical follow-up (especially for the women out there):

Reminding you that you do not have to apologize when you say no; it is, in fact, a complete sentence.

We know that women apologize more than men do, for a variety of reasons (many of which are socially/ culturally encoded).

Our tendency to over-apologize may be attributable to a confidence gap exhibited by women, even amazing powerful women.  The overuse of “sorry” can- and often is- seen as a sign of weakness.  We need to hold each other accountable for the abuse of this poor little word, giving each other a friendly nudge when we catch each other (or ourselves!) apologizing for those things we can’t control, and apologizing for things that really don’t merit it.

This piece from Medium captures the author’s quest to decrease her inappropriate apologies over the coming month.  I particularly like her friend’s comment about only apologizing if he acts in a way that is inconsistent with his values.

I’m obviously not advocating for complete abandonment of common courtesy; I was raised south of I-40 and my Daddy was in the Marines, meaning manners are paramount in my world.  What I am challenging each of you and myself to do is to be authentic, to state our intention rather than taking the easy, “I’m sorry” route, and to only apologize when we really mean it.

I’ll count my abuse of the word “sorry” tomorrow and report back.  I hope you’ll do the same.

And do NOT apologize for saying no.  Ever.

 

Hanging on to our better selves

First, a confession about how this particular blog post came into being.  It all starts with an image of a panda bear that was included in the Tweet that Nick Kristof posted, linking to his NY Times piece on how we can increase empathy.  Chances are that I would have found my way to the essay anyway, but the panda…well, who can ignore a panda, right?  And I didn’t.

I’ve shared this great (short) video before in which Brene Brown (one of my personal heroes for her wonderful work on shame) explains the difference between empathy and sympathy, and the importance of connection.

What we know:

  • Empathy has been described as an essential capacity of physicians, impacting doctor-patient communication, patient engagement in their care, and the effective care of patients as a whole.
  • Empathy is also essential to maintaining physician emotional and mental wellness, including avoiding burn-out, depression, and suicide.
  • Student empathy scores (using a validated measurement tool) decline during medical school, specifically once students enter the clinical years.
  • We are ineffective in teaching students how to balance the presence of suffering with the maintenance of empathy, probably because we have historically relied up on the “hidden curriculum” to do this (and many of us do it poorly).

So how do we do this better?

Maybe the answer is in having a wellness curriculum for our trainees. Of course, there is the critical issue of getting our own houses in order as well- burnout has become a prevalent topic, particularly in the surgical literature, and we know that emotional exhaustion and depersonalization are predictive of burnout.  In the absence of much formal training, we just plain make it up as we go…so we practice yoga, we read literary fiction, we learn about meditation (and try mightily to sit still!), we look at pictures of cute animals.

Gratuitous Olivia Photo

Gratuitous Olivia Photo

Most importantly, we have to be brave when it’s not easy to be brave.  Our “culture” teaches us to chin up and keep going and sometimes that’s not the right answer- we need to pause to process, we need to talk to a colleague about what happened.  And we need that colleague to sit with us and say, “I know what it’s like down here, and you’re not alone”  No, “At least…”, and no offering of sandwiches.  Because, really, we’re all in this together, aren’t we?

 

Is MOC a mockery?

Maintenance of Certification, or MOC, has been discussed quite a bit recently in the American College of Surgeons General Surgery Community, was the topic for a JAMA Tweetchat earlier today (which I unfortunately couldn’t attend due to other obligations), and was the topic of a NY Times opinion piece on Monday.  For those who aren’t familiar with the concept, the idea of MOC is that the knowledge base in medicine is expanding exponentially, making the idea of time-unlimited specialty certification a bit of an albatross.  We all take our certification exams near the time when we finish our residency training; I’ve been out of my general surgery training a “mere” 10 years, I don’t practice true general surgery, and I assure you there were plenty of things I had to brush up on (and learn de novo) when I took my general surgery MOC exam last year.  When I took my MOC exam in critical care a couple of months ago, it required less preparation since much of it involved things I do every day.  Nevertheless, I found myself a bit put-off when I was asked to hand calculate a value for a patient; in the real world, I pull out my iPhone, drop in the appropriate numbers in my medical calculator app, and voila!- free water deficit calculated.

While MOC has been mandated by the American Board of Medical Specialties (ABMS), the component specialty boards of the ABMS have been given a great deal of latitude in what implementation of MOC looks like.  Done well, MOC will provide a foundation for us to provide better patient care in our day-to-day practice.  Done poorly, MOC turns into nothing short of an onerous and irrelevant box-checking exercise.  A common complaint lodged against the certification process, and MOC in particular, is that the system is being developed and delivered by individuals who are not in active practice; while this may be true for some specialties, I am grateful that surgery seems to be a marked exception.  Not only are those who have developed and implemented MOC at the American Board of Surgery (ABS) still in active practice and themselves participate in MOC, there is also a commitment to refining the process to best serve surgeons and our patients (see D. Mahvi’s “Report from the Chair” on Page 2).  Based upon Dr. Ofri’s Times editorial and this blog post describing shadowy financial practices by the American Board of Internal Medicine, my gratitude for the work of the American Board of Surgery’s work in this area is perhaps even greater.

Here are the basic struggles we are still faced with:

  • One of our junior surgeons informally polled recent graduates of her residency program recently.  They rated keeping up with the literature at an 8-9 level of difficulty on a 1-10 scale.  How can we facilitate this process?
  •  We need to keep up, or we’re not capable of providing best care for our patients.  But how do we best keep up in a way that enhances those patient outcomes?  Can an MOC system be designed that results in improved outcomes?
  • The system we have isn’t yet meeting us where we are in terms of the day-to-day delivery of clinical care.  For example, in surgery there are aspects of MOC that relate to practice assessment.  A closed-book MCQ exam?  That’s nothing like the real-world.  I commented the week after my critical care MOC exam that while I took the written at a testing center the week before, my ICU was giving me the practical exam on a daily basis.
  • In a feature unique to surgery, how do we know that an individual’s technical skills are safe, both at the time of their initial certification, much less when they apply for recertification?  How do we know that they are keeping up not just with the cognitive base, but also the technical base, to deliver quality surgical care?

Do I have a brilliant solution?  Honestly, I don’t.  I’m hopeful that the ABS will keep listening to those of us here in the trenches, and will keep refining the process.  I’m also hopeful that someone in surgery will find a way to replicate the two studies cited in Ofri’s opinion piece, allowing us to see if MOC done differently can be done “better.”  And most importantly, I’m hopeful that preparing for my general surgery MOC again in 9 years won’t be too onerous, especially if I remain committed to not taking out gallbladders.

 

How did I get here?

The last two days have been consumed for our research team with a site initiation visit for a BARDA-funded project; I’ve previously alluded to my interest in platelet-rich plasma in the treatment of burns, and this project is part of that project complex.  As part of the visit, I was asked to give our visitors a tour of the burn unit, something I did proudly.  Our new burn unit that opened this past Fall provides the perfect home for our amazing team and our patients.

One of our visitors asked me how it was that I ended up in Burns, giving me the opportunity to share my story with their team.  I honestly did not start my surgical training expecting to end up in burns (nor did I start medical school anticipating being a surgeon, but that is a story for another day about “clerkship converts”).  My intention was to become a pediatric surgeon, and the key reason I came to Utah for my surgical training was to have the opportunity to work with Dr. Dale Johnson, a luminary in the field of pediatric surgery.  Over the first few years of my residency training, I realized that I still genuinely loved working with children…but I started to suspect that I would miss caring for adult patients.  I also found an interesting paradox in my clinical skills and interests:  while I loved the intellectual challenge and the decision-making demanded in the care of critically ill patients, I also found satisfaction in elegant, aesthetic-like procedures. As a young surgeon, you can see how this set of skills and interests might be confusing to manage.

My last clinical rotation of my third year consisted of three months as the “chief” in our burn unit.  I took care of children.  I took care of adults.  I worked some incredibly complicated physiologic puzzles.  I did some basic burn reconstruction, scar releases and the like.  I worked stupidly long hours (remember, dinosaur residency) and found myself eager to be there in spite of that.  I got to know Drs. Jeff Saffle and Steve Morris, men who would become my professional sponsors and practice partners, and realized that they were my people.  I found a home.

And in that home…stories that sealed the deal and changed my life.  The young man who sustained a 20-something percent burn from an electrical flash and who developed the most impressive acute lung injury I have seen someone survive- and whose ALI improved almost immediately when we excised his burn. He issued a challenge to himself and our team for him to be discharged prior to his 21st birthday, and with hard work on both sides we succeeded.  The father and two children whose home was destroyed in a propane explosion.  I have countless memories of holding the baby (who is now in junior high) upside down in my lap when I was finishing paperwork in the afternoons and evenings and Mom couldn’t be around.

In telling these stories, I was reminded- as I often am when I have a rare quiet moment to walk around our ICU- how truly privileged I am and we are to become part of these lives.  No, they don’t choose us; it’s a bit like our families, in which chance throws us together and the experience changes us all.

Burns?  I’m still not sure that I chose it.  It called me, and I keep answering.