Category: Surgeons are surgeons

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.

14192641_10154573798169175_3746831890642526318_n

(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.)

 

Tomorrow is another day…

Posted on by Amalia Cochran MD
Why do today what you can put off until tomorrow?
Why do today what you can put off until tomorrow?

It’s an activity that looks different for each of us- and it only applies to self-directed responsibilities.

It’s been identified as a basic human impulse, and one that we know is inherently irrational.

We do a remarkable job ignoring its consequences.

When I was in college and needed to write papers, it usually resulted in mass quantities of baked goods or a large roux pot of étoufée.

Now?  Well, now it occasionally (thought not always) looks like a blog post.

We are all, each of us, procrastinators by nature. The reality of a future benefit of whatever action or task we are putting off is far less significant to us in a given moment than the potential immediate gratification of something else we could do right now- particularly if the delayed action or task isn’t something we actually enjoy.  Those things in the future tend to be pretty abstract as well- and they are certainly more abstract than something sitting right in front of us.

Sometimes procrastination can be used to our advantage; poet David Whyte appropriately mentions that it may provide time for ripening of ideas. He also counsels that we should use procrastination as an opportunity to careful sit with why we’re delaying the action or task in question, reminding us that sometimes the time that it gives us provides us interaction with something much bigger than ourselves.  I’ve felt this more than once when I’ve given myself a bit more time than I might have liked while working on a manuscript, only to find that when I finally do get my backside into the chair that it magically ends up “just right.”

However…we all know that procrastination isn’t entirely to our benefit.  We know we need to keep up with our documentation, but sometimes the Epic inbox is just so…overwhelming.  We know we should respond to a couple of emails from colleagues, but we’re going to say “no” to something they’re asking us to do and we don’t want to disappoint them. The phrase I’ve come to use around the types of tasks we tend to put off even though they are necessary?  We have to eat our broccoli (or some other vegetable that may not be your personal favorite).

This week the HBR website had some tips and tricks on how to beat procrastination for those times when it’s not working in our favor. I have a favorite from each group- in the first group, it’s thinking about how great you feel when that task is completed.  Admit it, it’s nice to have your Epic in-box empty. For the second group, it’s figuring out the first step that you need to take to get started; this concept works best for more abstract, bigger things (like starting a manuscript).

So, what are you going to get done today that you’ve been putting off?

 

 

 

Staving off the demons

Posted on by Amalia Cochran MD

This review of burnout in surgeons was published online in JAMASurgery last week, as was this Viewpoint on resilience and its relationship to burnout.

Of course, the root causes of burnout in medicine and surgery are protean. Specialty, gender, workhours, EMRs (yes, the EMR is being blamed now), basically anything that can contribute to job dissatisfaction regardless of profession are possible catalysts for burnout.

I openly admit that I don’t spend much time discussing burnout. It’s not that I don’t care when my colleagues are suffering; I do care deeply about them and their distress. For me, it’s that discussions of burnout and “what’s wrong with surgery/ medicine today” tend to be problem focused.  While people have generated all sorts of inquiry around risk factors for burnout and descriptions of its impact, resilience and recovery are woefully neglected. And yes, our systems should try to help mitigate controllable things that are clearly risks…but there’s so much more to the picture than the systems, and those other things get complicated.

I’m also not saying I never have a sense of being burned out. There are weeks when I fear that I’m generally in over my head, when I’m exhausted, and when I feel like I have very little control over anything. Had you asked me to fill out a Maslach Burnout Inventory at 11 pm last Friday night, I’m reasonably certain that I would glared at you and ended up with a score very consistent with burnout. In contrast, had you asked me to complete one at 11 am on Saturday (after 6 hours of uninterrupted sleep on Friday night and an 8 mile run with my running “tribe”), it probably wouldn’t have looked nearly so dismal even though I was back in the trenches of patient care and was having a busy day.

Here’s the thing: I could have skipped my Saturday run and slept more, and I’m certain some would say I should have done just that. However, physical activity that is a challenge is both grounding and restorative; thus my love of running and the basis for my nine half marathons in the last year. And while some days it really is about the running to process and running to manage on energy, Saturday was a day when it was running for connection. I knew that the best thing (again, for me) to get my head back where I wanted it, to feel like I had just a bit of control over my crazy life, and to enjoy simply being in the moment was to get up early and meet my running group.

8 miles later...
8 miles later…

I’m going to tell you that your mileage may vary- your “thing” doesn’t have to be running. But what your “thing” does need to include is connection. Saturday morning I needed time with these friends- friends who cheerlead, who love unconditionally, who are incredibly funny, and none of whom are in medicine. I didn’t need for them to understand what my week had been like.  I just needed to be with them for a while doing something that we all love.  Brené Brown is right– we are all hard wired for connection.

Find your tribe. Love them hard. Most importantly, spend all the time with them that you can.  What if it really is that simple?

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.)

 

 

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.

Zzzz….

Posted on by Amalia Cochran MD

I would start with a few comments about the Daylight Savings Time change that occurred yesterday, though I try to be civil here.  Let it suffice to say that I don’t enjoy my dark early mornings that are the “new normal” for a few more weeks again. I always whine a bit about this Spring change, particularly because the bases for it are weak at best. And while I seldom rail about sleep disruption from my travels, the energy drain I tend to experience from the time change is huge. And, of course, that has the potential to really impact my work.

Last month the Harvard Business Review published a terrific summary reviewing the link between effective leadership and getting adequate sleep.  I do think that sleep piece is without a question a big piece of it, though I also believe that fatigue in general affects our ability to engage in the four types of leadership behavior that the authors describe.  There becomes a domino effect where fatigue directly results in disengagement, and disengagement is intimately related to burnout. While a great deal of the discussion about residents and duty hours has been focused on the impact of adequate rest and safety, the truth is that the impact of sleep deprivation throughout medicine is far more insidious than we’ve previously estimated.

When I was in my 30s I honestly wasn’t as protective of my sleep- perhaps because I spent the first half of the decade finishing my residency before workhour restrictions went into place. As I’ve become a bit wiser (and, in association with that, a bit older), I have learned to better prioritize my rest, though I’m still not as skilled as I would like to be.  No matter how much I look at all of the professional advice- get off of your screens, turn the lights down, don’t eat late, don’t exercise late- some of those things simply can’t happen for me all of the time. When I’m not faced with clinical demands I certainly do my best, but it’s a very imperfect best. And while I have been largely successful in creating a 10 + 10 (meditation + free writing, 10 minutes each) morning ritual for myself prior to my morning walks with Olivia , I really wrestle with what my evening ritual could and should look like.  I’ve generally stopped sending emails after 830 pm.  I’m generally off-line an hour or more before I plan to go to bed. I generally read for 10-30 minutes before bed, depending upon what time it is when I sit down with my book and when the alarm will go off the next morning.  Nothing in the evening has stuck for me as well as 10+ 10 + dog walk, however.  I’m still working on this concept to figure out what works for me.

I’ll close by saying that I’m a realist.  I take call 1 in 3 averaged over the year, and when I need to take care of patients sleep becomes secondary. It doesn’t mean I don’t take a power nap when I get the chance (I love power naps!) or make a conscious decision about managing my energy in other parts of my life (yes, I do skip runs if I haven’t slept well). I’ve made a conscious decision that it’s okay to stop working at some point in the evening, especially because I’ve embraced that my do-to list won’t go away completely anytime soon.

And with that, I should close.  It’s after 830 MDT, after all.

Happy resting!

I really mean it this time

Posted on by Amalia Cochran MD

24901302900_3b7116279f_z

It appears that almost three weeks ago I committed to getting back to posting on the blog.

I also appears that I have not been successful in posting for the last three weeks.  I’ve come close many times and just haven’t successfully overcome the “backside in chair” phenomenon that is required to generate blog posts or manuscripts or anything along those lines.

I could make up some excuses, but they would be just that.  And they would likely be silly.  I’ve had a fair amount of the ever-important time to think, I haven’t been that overwhelmed with work, and I haven’t been thrown any curveballs that messed up my game.

Instead, I’ll simply come back to writing, sharing the two foci of that recent time to think.

#1 On the concept of “preventing too many activities” (Item #3 of the 7 Characteristics of the Dharmic Person): Maybe this is my “excuse” for the blogging break. I’ve been really conscious lately of saying no to things that really don’t align with my goals and priorities.  I’ve also been spending time thinking about those things that don’t light me up like they used to and finding ways to effect change there. And, perhaps most importantly, I’ve been focused on not having too many things going on at a given time (and yes, that includes my tendency to multitask).  This idea of being really intentional and staying out of overwhelm is one that just makes sense to me where I am right now.  I do still care about the blog…I’ve just put other things higher on the list the last few weeks.

#2 On being grateful: I’ve spent the largest portion of my time lately considering how incredibly grateful I am. Part of this has been driven by travels in which I have consistently been surrounded by friends; from Baton Rouge to Austin to Bozeman in the last 5 weeks I have eaten very few meals alone, and I have been able to treasure time with amazing people who have become part of my life in a rich variety of ways. I’m fortunate to have the opportunities that I do to travel to beautiful places.  I’m fortunate to be able to run and do yoga and play outdoors. I’m fortunate to have clinical and administrative jobs that excite me and constantly challenge me, and to work with people in those roles who “get it.”  I have managed to revel in the little joys of friendship and adventure, and I’m grateful that I’m able to recognize how fortunate I am.

So, with that, I’m back.  And I mean it this time.

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.