Category: Leadership

Why teach?

Posted on by Amalia Cochran MD

This past week was Surgery Education Week, the annual joint meeting of the Association of Program Directors in Surgery and the Association for Surgical Education. It’s a meeting that I first attended in 2001 and I haven’t missed a year since. I say that not as a point of boast, but to highlight my enthusiasm for this meeting; a week with people who share a passion for all things surgical education is professionally reinvigorating.  This year it definitely happened at the right time for me to get my bearings back.

My friend Chris Brandt was our ASE president this year, and he delivered a personal and heartfelt Presidential address on Thursday. Within the context of his speech, he asked an important reflective question for me as an educator, and one that I suspect will resonate with many of you:

“Why teach?”

Some of us fall into teaching semi-naturally; for me, it started with Vacation Bible School and helping in preschool Sunday School while I was still in high school, then teaching preschool part-time for part of College.  I  taught while I was in graduate school (if you haven’t read Dr. Seuss’ Butter Battle Book, you obviously weren’t in one of my international relations sections), and the one thing I knew in medical school before I was certain that I wanted to be a surgeon was that I wanted to teach.

But why?

For me, it’s the idea of paying it forward.  I’m certainly not going to wax philosophical about how every single teacher I’ve had has been amazing- that would be a flagrant lie. That said, I can tell you about my teachers who really made a positive difference for me. Steve Hoemann (English, 7th Grade). Carole Buchanan (World History, 10th Grade). Louise Bianchi (Piano teacher, 9th-11th Grade). Claudine Hunting (French professor, Undergrad). Mike Ward (Advisor/ International Relations, Graduate school). Jim Knight (Leadership in Medicine, Medical School). Danny Custer (Pediatric Surgeon, Medical school- I “blame” him for my career in surgery!). There’s one common thing that each of them did and that I value immensely: they made me better in some way. I know that I would not be who I am doing what I do in the way that I do it without this group of people, only two of whom actually knew each other. I also know that I am fortunate that they believed in me enough to challenge me, enough to push me out of my comfort zone, because they saw potential.

Why teach?

Because now it’s my turn to find that potential in learners, to nudge them out of their comfort zone, to help them be better.

Besides, the emails and notes that you get for this are pretty awesome. I can’t read any of them without smiling and thinking, “THIS.  This is why we put in the extra effort, the extra thought, the extra time.”

So, what’s your story? Why teach?

Searching for meaning in it all

Posted on by Amalia Cochran MD

If you’re not someone who reads The Oatmeal on a routine basis, I’m not going to chastise you right now (though having a baby vs. having a cat is fantastic and you’ve totally missed out).  Instead I’m going to refer you immediately to a recent post on unhappy. (h/t Jessica Blumhagen, excellent surgery intern and human)

Now that you’ve read that, I want you to think about if you are truly, completely joy filled every moment when you are doing the things in your life that mean the most to you.

I’ll start: I’m not.

Do I have those moments of indescribable joy when I’m doing my clinical work, when a learner has an “Ah-Ha!” moment, when I finish a half marathon…you know, those things that I find to have meaning?

Sure, I do.  But it’s not every single minute that I’m there. Some days it’s a vast minority of them.  Recent example: I ran the Bozeman half marathon on Sunday morning after a fairly tough call week.  It showed in my performance, which was still a strong run (just not my best). I had LOTS of not-so-fun, definitely not joy-filled moments during the run, even though the scenery absolutely helped. When I was 100 yards from the finish line and looked over to see my mom and my Olivia-dog? Joy.  And a reminder of my accomplishment, something I am lucky to do.

And during my Sunday run, as we’ve all had in the midst of meaningful activities when we get into a “zone,” I also was in that amazing state of flow. It’s a state that as surgeons we find ourselves in during the middle of one of those great cases, when it’s all just going and you’re completely wrapped up in it and nothing can get into your bubble. It’s something that my running friends will recognize when you realize you’ve just clicked off 3 or 4 miles seemingly effortlessly.

I love the idea that to achieve flow that you need to do things that are challenging to you- it’s not the easy stuff when it happens. Matt Inman’s description of being “perfectly unhappy” aligns nicely with that idea when he talks about running 50 miles, reading hard books, and working long days.  I think that his comic struck a nerve for me because distance running (not 50 miles!), reading literary fiction, and well…y’all know about my job…anyway, I understood what he was saying about doing things that are meaningful to us and the importance of that even when those things are hard.

I’ll give my usual disclaimer: your meaningful isn’t going to be my meaningful. You may not run, and you may not love complicated books, and you may not have found “your” career niche.  That’s okay, and it’s important that we each be a little different from one another.

But I did want to remind us all (and perhaps maybe myself more than anyone right now) that it’s not going to be fun every day and it’s not going to be easy every day.  What it should be every day is a celebration of doing something that is meaningful to you. My new going to bed at night question that I ask myself is, “How did you show up today?” It provides me a compass for meaningful activities every day, keeping my focus on doing those things that I love.

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(And thanks to Susan Piver for this lovely thought that was perfectly timed for my post. THIS is why we keep doing the hard and meaningful things.)

 

 

I’d like to phone a friend…

Posted on by Amalia Cochran MD

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

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

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

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

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

If you think you should call, call.

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

 

Words, words, mere words

Posted on by Amalia Cochran MD

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.

 

Celebrating, tempered with a few tears

Posted on by Amalia Cochran MD

I lost a friend this week.

That’s the selfish statement, and it’s the only moment I’ll take to be selfish and indulge in it being about me.

While I lost a friend, and someone whom I was so fortunate to get to work with on policy and advocacy with the American College of Surgeons, this loss isn’t mine, and I know it’s felt more deeply by some who were closer to him.  Chad was a role model, someone who I would easily say I want to be “when I grow up” (even though I think he would be displeased with me referring to him as being a grown up).

Chad’s obituary says little to help those who didn’t know him understand who he really was; you get an inkling from the picture with his fabulous, mischievous smile and more hints from the descriptions of some of the accolades he received.

When I started on the Surgeons PAC Board, it was an intimidating place.  I was the youngest surgeon in the room who wasn’t there as a representative of the residents or the young surgeons, and I was the only woman surgeon in the room. Chad was an immediate friend- someone who made it clear that my being there was important to the group and to him personally.  We bonded over policy wonk things, and we bonded even more over our devotion to our rescue animals.

Here’s the most important thing about Chad, and why I said I was celebrating as I write: he would not want it any other way. When I remember Chad, it’s almost entirely about his kindness, his generosity, his belief that we each really can make the world around us better and that it’s not an overwhelming task.  Chad was smart, he was funny, he was talented, and he cared deeply.

My wish is that each of us today will dig deeply to be a little kinder, to be a little more thoughtful, even in moments when it’s not easy to do so (or particularly in the moments when it’s not easy to do so).  I’m also remembering this week the importance of making that call, finding the time for that friend.  You just don’t know when it will be the last time you get to be with them.

 

(N.B. I drafted this a couple of days ago, before Philando Castile was shot and killed and before last night’s unimaginable events in Dallas. I thought about keeping the blog dark today because of those events, mostly because I simply have no adequate response to what’s going wrong in America right now. Then I decided that I was going to post remembering Chad because he was so filled with kindness and goodness, and that is EXACTLY what we need more of right now.)

 

 

Time’s up!

Posted on by Amalia Cochran MD

Meetings.

The beast that is a necessary part of what we do when we work in teams and groups.

An activity that can either energize us and focus our efforts or drain us and lead us to disengage.

I love a meeting that is focused, that is well run, and that lets everyone at the table have an opportunity to weigh in.  I particularly love it when we’re able to “wrap up” with next steps that include accountability for team members.  Putting those items into meeting notes then following up on commitments are how we become more effective.

I loathe a meeting that meanders, that belabors points, that allows those who talk a lot to monopolize the group’s time, censoring the wisdom of those who don’t always speak up first.  Good ideas don’t necessarily get a platform, and those holding those ideas may end up not feeling valued.  Again, disengagement is where good organizations go to die.

I’ve recently been experimenting with a couple of new spins on meetings.  One is the idea of not scheduling them for the Outlook-mandated hour; most of my meetings get scheduled for 45 minutes.  This is conscious because (1) very few things actually need a full hour and (2) it gives me travel time/ recovery time/ task switching time in between.  I’m particularly possessive of the buffer when the prior or following meetings are ones that I anticipate to be challenging or complex. Some have advocated for 30 minute meetings, a practice I haven’t yet quite adopted. Perhaps that’s next.

The other experiment is putting a time stamp/ shot clock onto meeting agendas that are tailored to how long discussions should optimally take. While this forces an adjustment for groups that haven’t worked with them before, they definitely do adapt over time…and it helps keep the meetings on-target and on time.  Two things are key to making the shot clock work.  First, have a timekeeper who keeps everyone honest and lets you know where you are versus the allotted time as it approaches.  Second, have a “parking lot” for ideas that come up and don’t fit within the boundaries of the current discussion.  During the meeting wrap-up portion, make sure to generate a follow-up plan for things put into the parking lot.

Happy time-effective meetings to you!

 

Hangry in the Hospital

Posted on by Amalia Cochran MD

Admit it- we’ve all been there.

You’ve got all of 5 minutes to get lunch before the next thing on your schedule and your pager goes off about something that needs your attention urgently.

You haven’t peed in 10 hours and a staff member who needs something for a patient starts to follow you into the bathroom (even though the patient need is not truly something urgent).

You’ve been taking care of everyone but you for the last 29 hours, a patient decompensates, and you’ve got to handle it because no one else is available.

You get paged at 2 am for berry blast tums because the patient doesn’t like the usual flavor (yes, this actually happened, though not to me).

The truth is that our healthcare system isn’t well designed for us to partake in self care.  While I know it most intimately from the ICU physician/ surgeon side, I see it exacting similar tolls on nursing staff, aides, PTs and OTs, pharmacists…really anyone who is involved in the nitty gritty of patient care. We get hungry (or hangry), we get tired, we get pulled in at least 6000 directions, all because we’re trying to do our best to take care of the patients and their families.

On Tuesday my team and I attended the March installment of Schwartz Rounds at the University of Utah, and the title of the session was the same as the title of this blog post.  We got to hear from people who work in the healthcare environment in very different roles and get their perspective on how challenging our jobs as caregivers make it to take care of ourselves, and there was a great discussion about the role that culture plays in that.  If I ask the staff to try to let me catch a 20 minute catnap while it’s slow, am I perceived as weak? If I call my supervisor to let them know I’m currently overwhelmed with patient demands, does that make me an incompetent resident? Putting those potential opportunities for shame into context was, quite honestly, eye opening.  Our culture in healthcare mandates that as care providers we all run fast, leap high, and do all of the right things for everyone with a smile on our faces at all times.  Reality mandates this simply can’t happen because we’re all human.

We all have basic things that we can try to do to help ourselves just a bit.  I have a cache of healthy snacks at all times and I have two water bottles in the hospital (one in my office, one on the ICU).  One of my “treat” tricks is that I have a stash of teas that I can brew up for me, which is an inherently stress-reducing activity, and that I am willing to share with team members as a boost. I’ve been doing this more recently and I’m starting to wonder if good loose-leaf tea simply has magical calming properties, even when it’s got caffeine.

One of the things that struck me the most during the Schwartz Rounds discussion was the role that leaders and teammates can play in creating a culture where we’re allowed to be human, where we somehow manage to get something nutritious to eat, where we can actually function at our best because we’re taking care of ourselves in the little ways that can add up when we’re stressed and tired and hungry.  I realized as I was listening to a few horror stories that we are so fortunate in our unit to have a culture where we try very hard to take care of one another, be that by grabbing a coffee for someone’s morning fix, running to get someone lunch who is swamped, or simply having that willingness to step up and lend a hand when it’s crazy so that no one person has to shoulder too great of a burden.

Here’s my challenge for each of us this coming week: Think about the things that you wish someone would do for you when you’re hangry in the hospital. Then offer to do one (or more) of those things for someone on your team. You never know when you’ll need the same favor, and I can assure you they’ll be grateful for the kindness.

 

 

 

Meanness about surgeons

Posted on by Amalia Cochran MD

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.

Stop explaining, stop talking.

Posted on by Amalia Cochran MD

One of the places in medical education where I am well-convinced that we are still failing our trainees is teaching them how to have hard conversations. It’s simply not a part of the curriculum, so they rely on role modeling; as we know, that role modeling is as likely to be negative as it is to be positive. We also know that our students lose empathy over the course of their clinical training, and that the loss of empathy contributes to physician burnout and all of the negative repercussions associated with burnout.  And, of course, there’s the simple issue of the fact that no one actually enjoys delivering bad news and having hard conversations with patients and families.  It’s emotionally easier to not have the talk, or to deliver platitudes, or even to provide that little bit of false hope they can grasp on to so you don’t have to be the bad guy or bad girl.

The erosion of empathy has been a long interest of mine for both personal and systemic reasons.  Personally, I know I suffered from a tremendous (and in hindsight somewhat embarrassing) loss of empathy during the 100+hour workweeks of my residency, and that paucity of empathy applied to pretty much everyone, not just patients and families. I’m not saying I do it right 100% of the time now, but I’ve at least developed a tool set so that I’m usually aware if I’m entering an empathy-loss danger zone. And, of course, I’m interested at a systemic level because of the impact that empathy loss has on professionalism and our ability to work effectively as a team member or leader.

In order to remind everyone about the difference between empathy (healthy, connecting) and sympathy (not healthy, disconnecting), here’s a brief video lesson:

 

So, empathy is feeling with people. Courses are being developed to help us respond to patients and families in a more empathetic manner, and those courses often prescribe similar interventions:

  • Give the patient/ family, not the computer, your undivided attention.
  • Sit down!
  • Avoid medical jargon. Remember that part of medical school was learning that 2nd language of medicine- how would you explain this to your Aunt Velma, the 3rd grade teacher?
  • How you say it may matter as much as what you say.
  • If the patient is telling you about their feelings, don’t respond to them with facts. Doing so implies that you’re not hearing them.
  • When you’re scheduling a hard conversation, allow more time than you expect it to require.  This is not a time to be in a hurry.
  • Stop explaining. Stop talking.  Sit in the silence, no matter how uncomfortable it makes you. I love the quote that “doctors are explainaholics” (because we are).  Again, stop talking. It’s amazing what you can learn when you give people time and space to share with you.

As an additional aside, I would add that fostering these communication skills is also helpful for having hard conversations as a leader. While some of the details are different (you can probably use medical jargon with a junior colleague if it’s needed), all of the other rules absolutely apply.

Empathy is hard. It requires work, and it’s something we have to practice routinely in order to become good at it- much like being a surgeon, being a musician, or being a person. We need to recognize when we’re offering up unhelpful silver linings (or sandwiches) rather than genuinely connecting.  It’s scary, but it’s also worth it for our patients, their families, our colleagues, and ourselves.

 

The secret ingredient

Posted on by Amalia Cochran MD

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.