Pythonic habitats

Confessing my guilt up-front about two things:

  1. It’s been a while since I wrote here. My best excuse (and it’s pretty true) is that the energy I might have spend blogging during the academic year was instead expended upon brief writing assignments for my graduate coursework. If you’re interested in any of my discussion topics from Indigenous Food Systems and/or Federal Indian Law & Policy, I can accommodate you. And with that nod, an acknowledgement that I have every intention to do better about sharing my thoughts with you starting now.
  2. Today’s title was intentionally chosen because this concept has captured my attention. No, there will not be gratuitous snake photos to accompany the post. I am not a fan of snakes. I am, however, a fan of the concept of pythonic habitats because they account for a not-uncommon phenomenon I’ve witnessed in academic medicine.

The amazing Dr. Mary Brandt referenced Rev. Larry Kent Graham’s book on moral injury in a recent talk she gave as part of the American College of Surgeons Leadership Summit. I was in the midst of preparing a grand rounds on well-being in surgery, so I promptly ordered the book because I had a sense it had important lessons to share. And, indeed, the link between moral injury and absence of well-being is almost undeniable.

A foundational section of the book discusses what Graham describes as the “four intersecting conditions” that give rise to trauma, with trauma defined to include moral injury. While all of the others- explosive assault, a road wrongly taken, and grievous loss- can seem intuitive, the words “pythonic habitats” made me sit up and notice differently. These “benign, constricted, and dangerous environments” slowly and inexorably “squeeze the life out of us.” He initially discusses relatively obvious pythonic habitats, in which people constantly live on the edge of situations that are a danger to life and health- there’s no single defining event, but instead a series of threats that require ongoing vigilance. Although Graham provided a more complex example of individuals with access to the nuclear triggers or who guide drone warfare, in which they do isolating work with moral consequences then go home to have dinner with their families, when he mentioned “benign normality” of their daily lives I immediately thought about the work that we do in medicine.

Think for a moment about the things that we do as part of our work caring for other human beings; surgeons, I’m particularly looking at us. When is the last time you had an experience caring for a patient that you can discuss quietly with a colleague- out of earshot of non-medical people- but wouldn’t dream of discussing over dinner at home? The reality is that we are witness to or actors in situations all of the time in our work that isolate us and that demand that we compartmentalize our lives. And somewhere along the way we all decide that it’s just business as normal because it’s what we have to do. Here’s a hint: it’s not normal, even though it may be necessary, and that causes moral dissonance for us.

Pythonic habitats struck me because while they are unavoidable in our profession, we generally don’t acknowledge their presence. We become the proverbial frog in the cold water that gets heated up until the water is at a boil, and the only escape tools we learn are those we see in the hidden curriculum; there’s little intention in how we all deal with this unrelenting constriction. Over time, unless we do consciously address it, that constriction takes a toll on our physical and mental health. And, as Dr. Jillian Horton states in her beautiful recent book We are all perfectly fine, “Most doctors look fine, perennially, until the day they don’t. That’s because doctors are excellent at compartmentalizing. We are also compliant and conscientious and rigidly perfectionistic, characteristics that put us at risk for choking to death on our own misery.”

I’m not going to profess to having a perfect solution for dealing with these pythonic habitats, though I am committed to seeking a remedy that will help to keep us whole. My hope is that by naming it- and acknowledging that it’s not normal- that at least gives us the possibility of moving towards recalibration and healing.

Well, THAT was a year!

“I’m apprenticing myself to hope and learning as much as I can. I’m making space in my mind for the good thoughts, so they can nestle in and sing.” – Maggie Smith, Keep Moving

I suppose I’m doing a bit of bandwagon hopping, though as we’ve moved through the first half of March it’s pretty hard not to reflect on the last time that things felt “before-times” normal. The truth is that we are marking an anniversary right now that most of us didn’t think would need to be an anniversary, and the implications of that anniversary are heartbreaking, frustrating, confusing…and yet it seems irresponsible to ignore some of the good things that have come of Our Pandemic Year. If you entered March, 2020, struggling in your ability to hold “both/and” type mindsets, I suspect this year has expanded this skill set for you.

Let’s start with the assumption that you, like I, didn’t see the duration and severity of the pandemic coming- or at least not from the seat you were in on March 12th, 2020. I was spending this week watching professional meeting dominoes tumble as the Committee on Trauma, then the American Burn Association, then the ACS Leadership & Advocacy Conference were serially cancelled. Elective OR cases quickly became a thing of the past. Medical students were pulled from clinical services. I found myself online ordering masks so I could at least have an au courant fashion accessory (have you SEEN my triple layer fabric dinosaur mask?!?). It was as if life went from 1000 miles per hour to a snail’s pace.

That pace change is arguably what I will remember the most from this year.

Now, I say that recognizing that I had decided to take a sabbatical prior to the pandemic becoming what it ultimately became. I already knew that I would benefit from some unstructured time to be creative, to learn, to reconnect with family (and framily) that had I been failing to center. It had also become clear to me that I needed to make decisions about my professional commitments for the next 10-12 years; my efforts to keep one foot in the world of medical education and the other in the world of burns and critical care was resulting in no balance among any aspects of my life (personal or professional). The one thing that I knew for myself prior to “pandemic” inserting itself into all of our vocabularies was that what I was doing and how I was living wasn’t sustainable in any way. Well, that, and I wasn’t going to keep doing it.

Today isn’t the day for me to wax poetic about the sabbatical experience so I’ll simply say that it’s been everything that I hoped for and needed. I’ll also gloat for a moment and share that the last winter when I got in this many ski days was 2001-2002 (for those keeping score, that was my professional development year during residency). More on all things sabbatical in the future.

As part of processing this pace change, I’ve also spent time considering what I want to take forward with me to the “after-times” as we see glimmers of hope on the horizon. So, what do I hope is durable?

  • Weekly, or at least very very regular, virtual happy hour with a dear friend. I think in the last year we’ve missed 4 weekends, which almost makes up for the absence of in-person time (though we have also calculated that it’s “just” a 12 hour drive from Portland to Bozeman and we are both fully vaccinated now).
  • Gathering outdoors when the weather is suitable for it anyway. Why weren’t we/I doing more of this?!?
  • While I miss the soul nourishment of seeing colleagues from other places, I have loved sleeping in my own bed and learning virtually with professional meetings. Are we really going to go back to those wild academic travel schedules we endured? I’ll be surprised…
  • Framily/ COVID bubbles are amazing, and I’ll be keeping mine if/when I re-settle away from Montana. Granted, the core of mine has been my residency “sister”, her husband…and their 5 kids; we’ve simply reunited and built on what we started 20-something years ago. Having them close by has made the Montana portion of the COVID year not just manageable, but downright fun. I do NOT have enough gratitude for these humans, even if one of the 9-year-olds is eternally convinced that he’s taller than I am (he’s not…yet).
  • Old fashioned cards and letters. I’ve sent more cards and letters this year than I can count, and I hope they’ve done as much good for the recipients as they did for me to write and send them.
  • Honoring mental health. Although the pandemic has been hard on mental health in many ways and for many people, the fact that we have space to acknowledge this seems like such a quantum leap. Y’all, it’s okay to not be okay…and it’s okay to ask for help.
  • Sabbaticals. No, really, we need to normalize this. But, again, that’s for another day.

What will you remember most from this year?

And what do you hope doesn’t go away in the after-times?

The elephant that pooped in the living room?

While I have no intention of focusing this post on the still-somewhat-mindblowing events of January 6, I also would be remiss to not at least acknowledge that something horrifying (that looked an awful lot like a failed coup attempt) happened in Washington D.C. on that date. I’ve been pretty inarticulate in my thoughts so I was incredibly grateful when HBR published this piece today on the loss of trust associated with last week’s events, as well as what is required for the United States to move forward. I also think it’s important to mention the authors’ emphasis on holding those responsible accountable for their actions, something which quite a few people seem to think gets in the way of “unity.” Perhaps “unity” needs to be viewed through a lens of “recovering core principles of democracy we can agree upon” rather than simply giving people a free pass. Have any of you who have raised children made a choice to “go along to get along” rather than holding them accountable when they’ve violated a household rule?

Whew. Now that I’ve said more than I intended about the elephant that is clearly not in the corner of the room (nor is he behaving himself!), I wanted to address a different aspect of news cycles and pandemics and winter blahs. Kristen Neff’s work on self-compassion is a bandwagon I jumped on a while ago, and I can think of NO better time than the middle of January, especially this January, to remind you to be kinder to yourself. I know that there is so very much “stuff” out there about self-care, and some of it seems very woo-woo- and, if we’re honest, victim blaming. If you just did more yoga, or meditated every day, or attended virtual church each Sunday, if you would just do those things, you would be okay.

Or would you?

If I’ve learned one lesson about self-compassion, it’s that the true objective is to treat ourselves with respect and honor. It means not “should”ing all over ourselves (I should have done yoga, I should have meditated this morning, I should not have had that second cup of coffee…you see where this goes). Self-compassion isn’t a “free pass” when you really truly mess up, as we all do because we are human. Instead of prolonged self-flagellating (something surgical residents are often particularly gifted at), it allows you to take a step back, to own your part in something bad that happen, and to move forward by starting over. Assuming that you are someone who is kind to your friends, it asks you to treat yourself like you would treat a friend in a similar situation; if you tend to yell at your friends and tell them they’re total screw-ups when they’ve made a mistake in their life, we probably need to have a different discussion anyway…

I want to give you something helpful as we think about self-compassion, and there’s a “nudge” question that can be wonderful when we’re “stuck” (with that stuck being a nasty internal monologue about ourselves, or doom scrolling, or whatever not-healthy coping mechanism we find ourselves using).

What do I need right now? Right in this moment, what will help me the most?

Sure, sometimes it’s going to be some sort of indulgence (moderation, please, with the indulgences). Sometimes it’s something as simple as “I need to get offline” or “I need to get outdoors and go for a walk.” I find that what I need right now is seldom complicated or messy…and if it is, that’s food for additional thought as well.

What do you need right now?

Go and do that. And don’t “should” all over yourself in the process, please.

2020, what lessons you taught

Hi, readers.

Remember me?

Yeah, I know, I said I was going to double down on my writing efforts with the move to Montana.

And then graduate school. And then some clinical work. So many distractions. For those who are fans of Pixar’s Up, this is when I invoke the phrase “Squirrel!”

It feels like it’s time to begin again, and I can’t think of any better way to do that than to share my biggest lessons of 2020 (which felt more like a decade than a year…is that just me?). Because, all of the social, political, and economic wildness aside, 2020 was undoubtedly a year of learning for me.

  1. Grace, grace, and more grace may be the most important quality we can offer. My comment above about “begin again”? That’s grace, and in this case I’m offering it to myself. I find that many of us are terrific about offering those around us grace, reminding our friends that they can always begin again; yet we aren’t so generous with ourselves (see Kristen Neff’s work on self-compassion). What if we spent more time offering that bit of compassion to everyone, and especially to ourselves? What might that look like?
  2. Old friends, they shine like diamonds. Surprising no one who is a long-time reader, I found some wisdom in music this year. Chris Stapleton’s “Starting Over” was the album of the last part of 2020 for me, and it includes the song “Old Friends”. My clinical work has been in the ICU at the hospital where two of my residency classmates are general surgeons, and since it’s about 2 hours away I move in with my “residency bestie” Katie and her family when I go over (for COVID purposes, we just treat me like I’m a full-time live-in family member). I’ve been reminded why residency was hard AND do-able with these humans, and I also realize that I’ve been closely surrounded by really amazing, generous, and kind people for a long time. As Jeff explained to his 10-year-old son, “We’ve been through THINGS together, and we’re still close because of it.” Amen.
  3. Sometimes you just have to leap into the unknown. When I came to Montana this summer, the thing I knew with certainty was that I had a one-year lease on a place in Bozeman. The other thing I knew was that I planned to take my first summer off since 1989 (yes, you read that correctly…the year I graduated from college was my last “summer vacation” thanks to a torn MCL). I trusted that with some time to rest and be outdoors in wild spaces that I would figure things out, and this has generally proven to be true. Graduate work in Native American studies has proven grounding, and I’m loving spending time in the virtual classroom as a learner. Doing ICU shifts has kept me tied to clinical life and has provided another avenue for learning (thanks, COVID…I’ve been learning SO much about you!). I’ve spent time in the sun riding and running and hiking- and now skiing. I’ve written (and scrapped) the lion’s share of a book proposal. Most importantly, I’ve developed a lot of clarity around what I want my last 10-ish years in medicine to look like.
  4. Boundaries and (adequate) resources matter. Over time, I plan to build these themes out more as key elements of effective leadership and tools for mitigating burnout. Part of 2020, for me, was learning about setting boundaries and how to handle it when they’re not being respected. I also realized, thanks to a comment by a respected mentor at the close of the year, the impact of resources of all types on success and well-being. And, of course, I see a straight line between setting boundaries and having adequate resources to do what is being asked of you; as I’ve written before, burnout is not a failure of resilience and victim-blaming is ridiculous in settings where people are consistently being asked to do more with less. These concepts around boundaries and resources are an unfolding idea for me right now, and I’m all but certain it will show up in a more complete form in the not-distant future.
  5. Celebrate ALL the wins. This is a lesson that I’ve apparently been slow to internalize, but that doesn’t make it any less important. How often do any of us pause to intentionally consider something we’ve done that is important/ meaningful/ just plain awesome? What if we started treating celebration as a practice, even when it feels silly to do so? One of my friends is doing a daily practice of #eveningwins, which I love as a part of daily ritual, and another has been encouraging those around her to pause on Saturday, look at the previous week, and celebrate at least one thing from the week. I closed 2020 celebrating that I know what I need, know what I want, and have the courage to pursue just those things. Last night’s installment in #eveningwins was getting a slightly-overdue book chapter submitted (THAT is a tangible victory!). Here’s to more intentional celebration for us all, both in 2021 and going forward.

Good stuff

Again I find myself at a loss for significant substance- we all only have so much bandwidth, right?- so for the second time this month I’m sharing what I’ll just call The Good Stuff. Because, pandemic and politics be damned, there’s plenty out things out there that deserve to be heard above all of that noise.

  • I’m admittedly of an age and from a place where the music of Tom Petty is a musical map of…well, almost everything. Last week, Wildflowers was re-released, more as it was initially intended since it was supposed to be a double album. While that alone was a source of joy for me, the hidden gem was a Rick Rubin interview with Petty’s daughter Adria, who was largely responsible for shepherding the re-release. I admit that I did listen to it on one of my favorite drives on the planet (down and then back up the Gallatin River on Highway 191) but it really was about the content, not the location.
  • Take a break. Go outside. Take a walk (or a run, if that’s your thing). And for heaven’s sake, go to bed. You’ll be better for all of those things.
  • I am admittedly a passionate advocate for public lands. They are one of many reasons I love the West as much as I do. This Patagonia-sponsored movie has beautiful cinematography, and while parts of what has been happening with our public lands are undoubtedly frustrating (shrunken Bears Ears, anyone?), I took the overall message as one of hope that many of us are passionate about these lands and being stewards of them.
  • May I share with you my all-time favorite pumpkin bread recipe? I mean, what on this Earth isn’t made better by brown butter and bourbon?
  • And now a challenge, or homework, asking you to send a random note or email or small gift to someone who is important in your life. It’ll make you feel good to do it, and I’m willing to bet it will make their day. I’ll admit that I got an unexpected package today from a dear friend and it was perfect…how would I NOT love something that is sparkly (the text is, though my photo captures that poorly) and has the word “radical” on it?!?

Looking for joy


Anyone else at that, “I just can’t even” point with the world right now?

My news consumption was already low, and this week I cut it by another 50%. It may reduce further, at least until the election is over, because I find that I seldom walk away from listening to the news and feeling good.

Last weekend I was discussing with a friend our shared need for hope, ease, and things that make us feel better right now. Acknowledging my own need, I wanted to share some Definitely Hopeful Things right now.

  • If you’re on Twitter and you don’t follow Maggie Smith (poet, not Dame Maggie Smith), do yourself a favor and follow her. Then take a listen to this interview with her discussing her life as a “recovering pessimist.” Then get her book that came out this week from your favorite independent bookstore.
  • While the finals are now over, Fat Bear Week is still an annual source of joy. And if you want to nerd out about why bears hibernate (and thus why being a fat bear right now is important), this Short Wave episode is a gem. Programming note: the bears are extra active in my part of Montana right now getting ready for winter, so if you’re out and about, please be extra careful.
  • Trust me about giving this a listen. The lyrics are inspiring (Yola). The vocals are amazing (Yola + Natalie Hemby + Brandi Carlile). And the keyboards and guitar? Not a day goes by when I’m not grateful for Sheryl Crow and Jason Isbell being on this planet at the same time as I am.
  • And if you want something to watch to make you feel a bit better about the world, I’m going to put in a vote for “My Octopus Teacher” (85 minutes, if you’re on a time budget). Available on Netflix.

I’ll close with a quote from Maggie Smith.

“Joy is always on time. Keep moving.”

Go find the light, friends. And don’t forget to share yours!

(And if there’s some form of art or entertainment that is currently leaves you feeling better than when you started, please share!)

September 2020 Reading Round-up

Am I the only person who feels like Fall snuck up on them? No? Just me? Anyway…

Anyone who has worked with me in ICU knows that one thing I’ve long been a bit noisy about it’s getting patients out of bed. Although this review shows that we have plenty of room for better evidence, early mobilization remains something we need to pursue-aggressively.

I’m pleased to see my colleagues who are editors of surgical journals making a clear statement on diversity in the editorial and peer review process; let’s please keep our energy behind this commitment.

I love the concept of gravitas, particularly because it’s something I’ve seen plenty of junior academics struggle with (and especially women!). I really like this HBR piece talking about cultivating gravitas. Tip #5 is the sine qua non for me- commit to integrity.

And, in other reading this month-

Current fiction:

Just starting this nonfiction:

And current group read:

Last but not least, I’ve spent a fair amount of time in the car this month with the Broken Record podcast, and if you’re a music fan, DO IT. Rick Rubin’s interview with Brandi Carlile is gold, and the interview with Justin Townes Earle, released posthumously, is nothing short of bittersweet.

Happy Fall, y’all.

Sunshine and rainbows and killer rabbits

I’m going to go out on a limb and say that some (all?) of you may have noticed at some point that our workplaces can take a toll on our mental health. Sometimes it’s due to things beyond our control (I remember a dreadful July a few years back in the Burn Unit that was no one’s fault). Sometimes it’s that painful stretch between work responsibilities and “life” things that can’t wait. Sometimes it’s a result of unhealthy behaviors or personalities that permeate the culture of a place. And, of course, in years like this one the factors influencing how we’re all doing when everything is uncertain are almost innumerable and the workplace is at best one piece of that.

I’ve also realized that when we are working as a leader that we have a responsibility to support the well-being, including the mental health, of those around us. That means actually listening when they’re explaining why they are struggling, and figuring out what solutions can be implemented. It means communicating effectively, perhaps to the point of having a sense of overcommunication. It means making sure that people are getting the down time (away from work responsibilities) that they both need and deserve. Sometimes it means being vulnerable- authentic- by admitting what’s challenging you or what changes you’ve had to make to adapt to “new normal”. Sometimes it’s having your child or your cat Zoombomb that conference call.

As it should have pre-pandemic, supporting your team’s mental health means asking people how they are doing and actually probing for an honest answer to that question. And when you DO get that answer that tells you they’re actually not okay, it’s your job to provide a more nuanced response than, “It will all be great!”

Positivity is an important feature of resiliency, and we all naturally want the “feel good” of being around people who are positive and make us feel good. However, sometimes the strategy of pushing positivity can have the opposite impact on the intended recipient, who will instead find that they are disappointed that they’re not happy, or frustrated thinking that they might be missing out on something that’s great. There’s a recently described concept of toxic positivity out there that is simply not helpful.

So, how can we support our friends and colleagues who might be struggling right now when we want to give them a gentle infusion of hope while we recognize it’s not all sunshine and rainbows? That’s when we try to achieve support and validation instead of, well, gaslighting people we’re invested in (HT: Mel Charbonneau, both for the reference AND for the acknowledgement of her own struggles right now).

Sometimes we all really just do need that reminder that we’re walking each other home, and some days that includes sitting with our friends and colleagues who are having a tough time. It’s okay to not be 100% okay, or even 50% okay; let’s offer ourselves and each other some extra grace. Don’t be a killer rabbit.

(Bonus points if you got the somewhat obscure Monty Python reference; here’s the clip from Monty Python and the Holy Grail if you didn’t.)

Working while friends

I’ll start with a not-apology for taking last week off; I was in the mountains and didn’t feel compelled to drag my laptop with me (even though the WiFi is better where I was than when I’ve been there in the past). Unapologetic sample photo of weekend activities here:

Prior to heading off for my R&R, I had been inspired by this HBR podcast on the benefits of work friends. I suspect it’s one of those things that many of us know but find challenging to articulate- while we don’t go to work with the explicit purpose of making friends, it’s a bit like school when we’re younger; it’s where we spend most of our hours, and those hours certainly go easier when we’re around peers who “get” us.

And, as one does, I started contemplating my work friends. From residency, there was an obvious choice. We spent almost every evening on the Shoreline Trail walking her dog, having those discussions you can only have with someone else who is surviving the indignities of surgery residency (especially under Old School Dinosaur Rules). When we both took off for our fellowships, we had regular phone calls because it’s hard being in a place for just a year and not having an actual peer group during that time.

Some 21 years after we first met (and 5 kids and a husband later for her!), it’s not possible for us to adore one another more. The best part? We’re only about 2 hours apart right now, something neither of us take for granted.

And, of course, when I went back to Utah, I was fortunate to have a mentor who became a dear friend. We worked closely enough with one another that we absolutely understood the other person’s challenges, but not so closely that we were in each other’s business. We had often been roommates at meetings when I was as resident (budgets, you know), and as faculty we continued that tradition. At one point, one of our colleagues pointed out to us that we didn’t have to stay together for budgetary reasons anymore, a comment we thought was hilarious mostly because it showed that they didn’t understand that it was about having time to catch up with each other, and we would often use the quiet time away from “regular” life to work on shared projects.

And then…we hired my junior practice partner, who is affectionately referred to as my “little sister.” When schedules permitted, we had opera and ballet nights, when they didn’t because of clinical service my Mom would feed us dinner, we supported each other with struggles, and somehow I even convinced her a trip to Cuba would be a good idea last year. I’m that friend…the one who convinces you to do the things you wouldn’t do on your own, but that are so good for you to do.

I’ve been fortunate to have had some tremendous work friends over my career, and particularly so since we’re all still on speed dial with one another. The pandemic has been hard on work friendships due to the loss of proximity. And sometimes work friendships go really, really wrong if someone has more needs than you can meet. I don’t want y’all to think that work friendships are perfect because they aren’t. But when done well (and with the right people) they make work life infinitely better.

August 2020 Reading Roundup

I’m quietly sitting here wondering how it got to be the end of August, but somehow it is. So, what’s caught my eye this month?

I don’t want anyone to miss this PNAS article showing that physician-patient racial concordance and disparities in newborn mortality. Take home? It’s another take-home for supporting DEI in healthcare since Black babies do better with Black doctors, particularly if they are a difficult birth. Let’s keep doing better in terms of expanding who we’re inviting to the “table” in medical school, and let’s also look at other racial/ethnic groups.

Colleagues at Northwestern did some terrific work that confirms what we all have long “known”/ suspected that patient outcomes are impacted by surgeon technical skills. I’m biased as the interviewer, but the author interview was a lot of fun as well.

I have a notorious soft spot for trying to improve rural/ urban disparities in healthcare, and I found this JAMA Network Open article looking at postacute care to be particularly interesting.

HBR (I know, I know, I’m not sponsored…) had an article on the importance of having friendships at work. The accompanying podcast is also worth a listen, and was a real reminder to the impact of work friends on job satisfaction and engagement. Stay tuned for another post next week on work friends.

And my other reading right now?

Fiction- lyrically written, and the story just wraps you in

Current nonfiction, which has been nothing short of fascinating:

And for our Antiracist Reading Group, the August book (which I have learned a great deal from was:

Happy end of August, all, and I hope you’ll all get a brief break for the holiday weekend.

Oh, and register to vote if you haven’t, okay?!?