I’d like to phone a friend…

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.)


Hangry in the Hospital

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.




Brave enough



Dear one,

Before I get too immersed in all of the other things that make up my crazy life, I wanted to write you a letter.  It was important to me that you know what you meant to me, what I believe you meant to our team, and how the last 4 1/2 months of your life changed all of us.

I first learned about you the day after you landed in our care.  I remember thinking that whatever your outcome from your injury that it was going to be hard-fought- and that was before I got to know you and know your family.  That was before I learned that just as we gave 110% for you every day (and I hope we do for all of our patients!), you gave 110% every day too- even on the days that it hurt and it was hard and scary.  That was before I got to see a very sweet smile, before I learned about your gift of silliness, before we knew about your love of Dirty Dr. Pepper.  That was before I got to know your parents, who are some of the most grace-filled people I have had the privilege of meeting in my life.  In short, it was before we fell in love with all of you.

I told your parents this week that while I will never be comfortable with the reason that we all came into each other’s lives, I will always be grateful for knowing you and knowing them.  I also often say that I have a collection of angels watching over me when I am doing my work- I believe our whole team does- and I now count you among them.  In our world, we are given the gift of taking care of people who make us all better people.  You were one of those people, and your family is some of those people too.

Our team started the week with a group hug in your honor, and I’ve lost track of how many hugs have been given among our team this week because of you.  We miss you.  We miss your parents.  We miss your brothers (though Natalie’s cell phone may not).

And I am so, so grateful for what you gave us this summer and fall as we loved you and cared for you and tried to put you back together.  While your light isn’t here on this Earth with us any more, I know that it brightened each of ours just a bit.  That is a gift that will have an impact for years to come.

Wishing you peace, dear one.  Thank you for being part of us and for being so brave.  You will not be forgotten.

Bringing the family into rounds

The idea of bringing daily ICU rounds, even once or twice a week, into patient rooms is a concept best described in the pediatric critical care literature.  It’s something that last year our group tried to start in our burn ICU, and I will openly confess that I’ve been a dismal failure at it.  It’s not that I’m uncomfortable with getting into the room and talking with patients and families about what’s going on- anyone who works with me knows it’s quite the opposite- but simply that I have struggled to figure out “best practices” and workflow to make these type of rounds effective for all of the parties involved in our interdisciplinary care team.  Every time I think about it, I find myself both challenged and overwhelmed, largely because my perception is that our daily interdisciplinary rounds (not always at the bedside) work just fine, though they are admittedly not patient and family centered.

So, the theoretical benefits of family-centered rounds:  increased family involvement and understanding, trainee role modeling, and enhanced team communication.  And the theoretical down sides? Physical barriers, trainee apprehension, and time limitations.

Interestingly, physician interest in conducting family-centered rounds seems to be driven by the physician’s perception of the efficacy of rounding in this way:  there’s an association between a belief in the benefits and the likelihood to do them, and there’s an association between perception of barriers and not conducting them. And, of course, the conduct of family-centered rounds requires that the physician leading them have tremendous situational awareness and an ability to manage the environment in order for them to be most effective.  Then there’s the whole sticky wicket of the fact that family-centered rounds may provide a foundation for family-centered care, they cannot alone insure that family-centered care is delivered.

After reading all of those things, I was still ambivalent at best.  I want to believe, and I want to deliver on our group’s agreement.  But how do we do this best?  How can I do this in a way that doesn’t feel contrived for me?

Fortunately, some guidance is present in this study, which provides descriptions of the “art” of bedside rounds as conducted on the medicine service.  While it’s not 100% relevant, I definitely see some tips in there I can employ- and in some ways I am motivated to “start small” by keying on a handful of patients rather than the entire ICU for each session.

So, here’s my late summer and Fall teaching and communication goal, out here for all of you to see.  I have a few weeks off service to ponder this and see what it will really look like, and a resident interested in education to help me pilot it starting in August.

Will it succeed, or will I at least overcome my antipathy?  Stay tuned!

Our house is a very, very, very fine house

Last week I spent three afternoons in a communication skills training course.  I had two real motivations for doing this, one related to my leadership role in the Department, the other simply because of my constant quest to find ways of doing things that are just a little bit better than what I’m doing.  At the Departmental level, I’m assessing what will be the best option for us to have in place for communications training for all of us- particularly with a view to creating shared language for our teams.  So, yes, trying to figure out how to do that best for all of us and our patients.

One of the best pieces I came away from the workshop with relates to patient/ family communication and was referred to by our fearless facilitator/ teacher as the “house model.”

Since we’re talking about effective communication, let’s be clear.  Nate didn’t mean, and I don’t mean, this House:

Negative role modeling, perhaps?
Negative role modeling, perhaps?

This house model, used effectively, gets us to a place of shared decision making with patients and families (credit to Bhang and Irengui for a less colorful but equally visual initial version of this):

House Model of Shared Decision Making
House Model of Shared Decision Making

If you look at this, it’s almost intuitive.  It certainly makes good sense.  For me, it put all of this information together in a way that I hadn’t synthesized it before- and perhaps most importantly that can be easily visualized.  If you think about a truly great discussion you have observed or had with a patient and/or their family, all of these things were present to help get to shared decisions consistent with the patient’s goals for their care.

The reality that often intervenes, though, is that the non-medical participants in the discussion get overwhelmed by the medical facts, and they don’t want to question the authority of the physician providing that information- or let us know that we’re speaking fluent doctor and gibberish for a normal human being.  And it’s too easy under pressure of time or emotion (feelings are SCARY- and they require time) for the medical participants to skip the “patient perspective” part of the discussion.  If you use the diagram I’ve drawn before, shortchanging either of those pillars gives you a lopsided house, a lopsided recommendation, and an incomplete ability to truly share in any decision making that occurs.

I go back on service on Tuesday, and I’m going to put my House diagram up in our call room as a reminder to myself.  I might even draw a second and/or third version of what it looks like when one side of it falls down as a reminder.  And I’m going to try really hard to consciously use these concepts over the next few weeks.  I hope that you’ll join me.


Building the perfect beast

Last week while I was off on Amalia’s Spring 2015 North American Tour, one of the highlights was moderating a breakfast session at the American Burn Association with the theme of “Building a high-functioning team in stressful environments.” We had a great group in attendance with diverse areas of practice in the Burn Team, with lots of wonderful ideas contributed from varied practices. I was fortunate as well to have a highly experienced nurse manager and a seasoned social worker (both of whom are already friends of mine) who helped me to re-direct the conversation during those inevitable moments when it was digressing. You know, human factors fallibility and all…

To prepare for the session, I did a bit of homework, trying to find key points and common themes in the business literature about developing high-functioning teams. Characteristics that are identified in many studies include the following:

  • Common purpose- For the burn team, this is built into why we show up to work every day.  We want to improve the lives of burn patients and their families.  Fin.
  • Clear roles- Who’s on first?  Again, within the burn team, this hopefully comes with the territory.  I’m a terrible bedside nurse and an amateur mental health provider, but I like to believe I’m a good surgeon and physician.  Airing our own dirty laundry, roles have been an issue as we try to move towards a two-attending system in our Unit; we’ve had many questions about who nurses should actually take questions to, and this is understandable for a developing system (and something we are actively working on).
  • Accepted leadership- Lots of subtleties to this one- it’s not just the “who is in charge” issue I take about above, but extends to the leader being perceived as effective by the team members. That trust takes time to build and isn’t guaranteed.  As a leader, there are plenty of things you can do to enhance that trust-building process and to move towards being an accepted leader, but that’s a blog post for another day (and, honestly, it’s a lot of hard work…so be ready!)
  • Effective processes- What I love here is that it’s not just about knowing what works and how to get there from here- it’s also about the constant reassessment of how we are doing things and if we have room for improvement.  If there’s one area in my clinical life I tend to lose sleep over, it’s how we can do things better.  It’s part of our unit culture, and it’s part of why we’re just under a month shy of going 600 days without a CLABSI- we figured out how to do it better!
  • Solid relationships- You don’t have to be BFFs with everyone on the team.  In fact, it might be better if you’re not.  Words that came up frequently in our breakfast discussion included “respect,” “trust,” and “reliability.”  It is entirely possible to respect someone but not be friends with them.  Without respect, though?  Dead in the water.
  • Excellent communication- Again, this was a recurrent theme in our discussion, with an emphasis on the two-way nature of communication between the team and the leader, and the importance of leaders (physicians, in this case) being receptive to communication.  If you question the importance of communication, this 2012 HBR piece shows that the single most predictive factor in team success is communication.  Remember: energy, engagement, exploration are the keys to communication success
    • One of my favorite tricks that I learned from a very wise surgeon (aka Jeffrey R. Saffle, my retired practice partner) is to partake of “bedtime phone rounds” at 10 pm each night with the ICU nurses.  If they have little stuff going on, they’ll hang on to it until you call.  It helps to ward off many things during the night.  And it reinforces that you are there for them and the patient.  

Are there other characteristics that you’ve seen in your work environment that have contributed to an incredibly successful team?  And how sensitive are you to when one of the “secret sauce” ingredients is missing?

More on effective leadership soon…perhaps in a couple of weeks.  I have other ideas stored up from my adventures!