Perfect Circle

Wednesday was a bittersweet day for me.

I’ve previously mentioned Danny Custer, whose last day operating at Baylor Scott & White was Wednesday of this week.  Danny had a remarkable career as a pediatric surgeon.  He was also our clerkship director when I was a medical student, and proved to be a huge influence on me. Even though I had no intention of becoming a surgeon when I started medical school, between he and Sam Snyder (and some really spectacular residents, including the husband of a college roommate) I was a “clerkship convert” to this crazy life.  Anyone who has been in my OR when I’m directing how long I want suture to be cut has heard the words “bunny ears” more than once.  I inherited that phrase from Danny. Danny was amazing with families, adored the children, taught with the patience of a saint, and made every day of “work” an incredible amount of fun.  His passion for his calling was contagious and I always, always mention him as part of my own story in medicine and in surgery.

Wednesday morning I got a text from one of my former student mentees who is now a resident at Texas A&M/ Scott & White. Kyle went to Temple knowing that Danny was one of my mentors, and I appreciate that he texted me the first day he operated with Danny as an intern.  Wednesday’s text was to let me know that it was Danny’s last day and that he would be operating with him for his last case.

My first reflection was one of gratitude that I have mentees out there who stay in touch.  Those moments are why those of us who teach pour our hearts and souls into what we do.

My second reflection was also one of gratitude that Kyle was operating with Danny on Danny’s last day as a surgeon. There was something incredibly special in knowing that someone I have influenced for good was helping to close out the career of someone who had such a positive influence on me.

Bittersweet.  And an absolutely perfect circle.


The Buddha Walks into the OR Part 5: Attention, Please!

It’s almost impossible to look around and not find something in media, in pop culture, in all sorts of places about mindfulness.  Interestingly, it’s not just out there in popular culture; my friend and fellow burn surgeon Sharmila Dissanaike led a session during last year’s American College of Surgeons Clinical Congress on mindfulness.  One of the ways in which she highlights the relevance of mindfulness is around resilience, which we know helps to protect us from burnout and career dissatisfaction.  In short, she sees mindfulness as a tool to expand our resilience and help us maintain our passion for our careers.

Mindfulness is also the 5th Paramita, or perfection.  Mindfulness takes practice, and over time it does cultivate the other perfections. An important feature of mindfulness in this context is the relevance of focus, and of tuning out distractions, in a way that we can concentrate on being in this very moment. As I write this, I’m suddenly struck by the serendipity of Tuesday’s blog on multitasking and cognitive bandwidth; even though I was writing about that from a pedagogical perspective, the key message was how we can help learners gain and maintain their focus so they can be more effective.

Susan Piver discussed meditation in one of her recent Open Heart Project weekly Dharma talks as a tool to unite the first four paramitas. Generosity and Patience both come from a place of opening that requires awareness and observation. Discipline and Exertion are more pointed and fierce, and are associated most strongly with mindfulness because of that focus. By putting Discipline and Exertion to work for ourselves, we are able to open to experiences in a way that demonstrates Generosity and Patience because we have more insight.

As surgeons if we are able to be right here, in this exact moment, then we are able to be more effective in our technical and cognitive work. As people, if we are able to be right here, in this exact moment, then we are able to be more compassionate caregivers for patients and families, and we’re able to be more effective team leaders. As family members, if we are able to be right here, in this exact moment, then we are able to be a more effective mother/ father/ sibling/ child/ parent/friend.

What is in front of you right now?

How can you use this moment to both focus on and open to what is around you?

Imagine the difference that mindfulness can make in your ability to both feel good and do good.

Be here.

Pay attention.

Blogger’s note: Heeding my own advice about being present and paying attention, you’ll have to wait 2 weeks for Paramita #6. It’s time for my summer break!

We can’t wait

Let me start with some simple facts.

Female surgeons have the same training as male surgeons; we go to medical school, we spend the same amount of time in residency, we sit for the same board exams.

However, if you compare the earnings of full-time female surgeons to our male colleagues annually, we make 24% less.

Here’s a question for you: Do you believe that this is right?

The reality is that pay equity is a family issue; when women aren’t paid equitably, over our lifetimes we make anywhere from $700,000 to $2 million less than men.  That’s not ideal for the economy, and it’s definitely not good for families. Pay equity also results in a more engaged workforce.

It’s important to me as the current president of the Association of Women Surgeons to make people aware of this pay equity gap; everyone I have mentioned it to is surprised by it, and since we didn’t train 24% less (or take boards that were 24% less intensive) no one seems to think this is okay.

And while awareness is important, it’s also important to understand what you can do about pay parity.  The AWS will prepare a white paper on this later in the year (stay tuned!) but I didn’t want to leave you without some strategies to get started.  Here are a few ideas, compliments of the AAUW.

  • Ask for, or generate, a workplace pay audit.
  • Encourage policies that support equity
    • Flexibility and family-friendly policies for men and women
  • Seek better benefits
    • Family and medical leave, health insurance, emergency family care, and scheduling meetings that don’t intrude on family activities benefit everyone
  • Write a letter to the editor or op-ed, or ask for a commentary time on local media

Other things you can do:

  • Educate yourself- Catalyst has great information, as does Evelyn Murphy’s WAGE project
  • Sponsor a workshop to educate your mentees and your peers about negotiation techniques
  • Share this blog post!
  • Options are limited only by your imagination!

April 12 is Equal Pay Day in the US; for those not familiar with the idea, it’s the day of the year when women’s pay from the last year plus the first 3 1/2 months of this year equal what men made last year. I hope that you’ll use this week as an opportunity to speak out and to talk about #fairpay. It’s time, and we simply can’t wait.



It’s just life. And choices.

A couple of weeks ago, I noticed this inspirational post about extraordinary success.  I’ll be honest that I really love most of the wisdom in it, and I’m likely to work through various pieces of it over the next month or two, simply because much of the wisdom resonates with things I write about frequently in this blog.

May has been wild and crazy in terms of deadlines and commitments.  A couple of weeks of clinical service.  AHRQ grant proposal due.  Trying to get out of ATLS Instructor jail (I forgot to teach in 2014 and my instructor status was due to expire this month).  Ogden Half-Marathon. Manuscripts to finish before mentees leave town.  In other words, lots of the usual stuff shoved into the same 31-day time frame (though, remarkably, no airplane time).

As I was reading through Jeff Haden’s post, #3 hit me like a ton of bricks.  “You don’t think work/life balance.  You just think life.”

I’ve previously bemoaned the concept of work-life balance (I still can’t stand that idea), and have also emphasized the importance of “no” as a central part of the professional vocabulary (when you say yes, it’s honestly forcing you to say no to something else anyway).  While Haden writes about your work being who you are, for most of us in medicine that’s even more true- our career, our calling is a central part of our identity.  I’ll admit that while the first thing in social conversations is definitely not, “I’m a surgeon,” it definitely sets parameters for my life and how I life it.  Those parameters aren’t good, aren’t bad…they just are part of the whole picture.

Can my cats write my research strategy for a grant proposal?  Well, no.  But does taking time out for a run or dinner with a friend make me a better surgeon?  No question that it does.  I’m also learning that the to-do list will ALWAYS be here.  It’s not going away, and the project post-its on my Personal Kanban white board in my office seem to multiply faster than bunnies.  Watching the sunset while I go for a walk with my dog?  Yep, that can’t be replaced and won’t always be there.  And my mind might be just a bit clearer for editing that manuscript when I come back.

I’m not saying we don’t ever deserve time off from work; I’ve made a deliberate move to take a day a week off from the projects and my email, and it’s honestly been helpful for me.  What I am saying is that if you’re obsessively focused on work-life balance, it’s quite likely you’re looking for something that doesn’t truly exist.  It’s all just life.

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!



Advocacy for beginners

This week marked the LAST in-class session for our 4th year students and we focused their afternoon on health care policy related topics.  There were some definite heavy-hitters there, and I had the privilege of providing a more practical session on advocacy.  I’ll admit- I was pleasantly surprised at how many students signed up for it, and also pleasantly surprised at how many of them had previously participated in advocacy in some way.  I’m hopeful that a few more will based upon the tips I gave them (and the fact that it’s just not that hard to send an email to your Congressperson!).

Based upon our discussion on Wednesday (and some crowdsourcing on Twitter), I generated an advocacy pyramid.  As you work your way up, the level of commitment increases- and the number of those involved at that level decreases.





Advocacy Pyramid
Advocacy Pyramid

When I crowdsourced on Twitter, one of the biggest comments that I got was that people have NO idea where to start- understandably.  I’m hoping that both of these pyramids give you an idea of where to start (hint: purple!).  In terms of writing letters or calling a legislator’s office, several of our professional organizations make it very easy for you.

  • For my non-surgeon colleagues, the most ecumenical was to engage with healthcare issues is via the American Medical Association.  Their Legislative Action Center for their Physician Grassroots Network makes it quite easy.
  • For those in Academic Medicine, the AAMC has an excellent resource as well.  Note:  To use their member action center you do need a AAMC login.
  • And, dear surgeon readers, please check out the American College of Surgeons’ SurgeonsVoice resource.  It’s your roadmap for surgical advocacy.

If you want an easy way to try out contacting your Member of Congress and Senators, I recommend going to the SaveGME website.  I’m reasonably certain if you are reading my blog that you share the idea that we are about to be in big trouble with GME (residency slots) in the United States, particularly in 2016 when we will have more medical school graduates than residency slots.  The medical schools have expanded to accommodate the projected need for more physicians, but we’re stuck with the same number of residency positions we’ve had since the Balanced Budget Act went into effect- so we now have a pipeline problem.  Help us fix the pipeline!

If you’re inclined, I would also encourage you to set up an in-district meeting with your Congressperson or Senators when they are back home.  Yes, you can do this.  Tip for first timers:  Take a “wingman” (or wing woman) who has done this before.  It’s less scary that way.

And fairly, a shameless plug to the surgeons reading:  Attend the American College of Surgeons Leadership and Advocacy Summit in April.  It’s a wonderful opportunity to rub elbows with College leadership, you get spoon-fed the process for doing Hill visits, and your appointments all get made for you.  Most importantly, someone from your state will usually have done this before, so you have that wingman I alluded to above.  If you can’t go this year, I encourage you to consider it sometime for the connections and the opportunities.

An important principle to remember is that you are in this for the “long game,” so to speak, if you really want to engage. You will not get a win on one of your policy asks the first time that you walk into a Senators office.  What you can do, though, is develop long-term working relationships with staffers.  These relationships allow you to become their go-to expert when they have a question or issue that is within your area of expertise.  I’ve cultivated one of these relationships, and they’re honestly quite a bit of fun to have- and it makes office visits in those particular offices feel more like fun and less like work.

So, get involved.  Send a letter, make a call on an issue you’re passionate about.  It’s an easy thing to do, and it’s an important opportunity in our democracy.


(Note:  Lest you think I’m ignoring the money side of the equation, PAC membership and the like, I’m not…I’m saving that for another day.)


The clothes make the…woman?

It’s consistently true that how we dress gives people a certain impression of us; it’s a way that we communicate nonverbally.  For many, there’s that idea of the professional “uniform” that gives them the proper identity.  Some of us target a look that is “professional but fashion forward” (my usual self-description).  Much like you wouldn’t expect an artist to show up in a skirt suit with a very traditional blouse, we don’t expect someone interviewing for a surgery residency to show up in a skirt and blouse reminiscent of Stevie Nicks in the 1970s..  Quite simply, there are fashion norms for all professions, and in order to have professional credibility, you find that you need to stay within them.

While the above is simply a reality, the one catch lies in the fact that women are often held to a somewhat more exacting standard than the men who are their colleagues.  Example, compliments of my own experience:  I was at a professional meeting in a pair of nice wool pants with a complementary jacket.  I was wearing brown suede Dansko Mary Janes that color coordinated with the rest of my outfit.  I was critiqued about my “shoe fashion sense” by a senior male colleague.  Now, those who know my lifelong shoe addiction well are assuming there’s a bit more to this story, which there is- I was nursing a broken metatarsal and simply couldn’t wear any other shoes except for running shoes (which seemed a  bigger faux pas at the time, but perhaps not).

Dear male readers, be honest:  How many of you have been publicly chastised for your shoe choice at a professional event by someone trying to mentor you?  I suspect it won’t be more than a handful, if that many.  But, somewhat ironically, the bandwidth of shoes that are considered “professional” for men is far, far more narrow than it is for women.

Lest you think I’m turning anecdote into data, think again.  Obese women suffer in terms of roles available to them and how much they are paid, but their male counterparts don’t.  Then there is the message in academia that “unless women dress modestly and conservatively, they look out of place in academia…they don’t have the right bodies to be academic authorities.”  This image preference for masculine styling for women to be credible isn’t a uniquely academic phenomenon, either.

So, what’s a girl to do if she wants to be taken seriously but doesn’t want to be a cookie-cutter of everyone else around her?

Personally, I have a stylist who knows that I’m a bit bound by a Very Traditional Career, but who also recognizes that I have no qualms about labeling things, “Boring!”  She does an amazing job finding things I consider smart- both in terms of their fashionability and because they navigate that narrow space I’ve got to work in.  That enables me to put together things like this, which are within the “rules” but quite the opposite of boring:

Mixed designers- Akris Punto (jacket) + St. John (skirt)
Mixed designers- Akris Punto (jacket) + St. John (skirt)

And, not surprisingly, I have a shoe “dealer.”  So that I can find functional but fun things like this:

Red Thierry Rabotins
Red Thierry Rabotins

As Don Henley said, I will not go quietly.

An elephant in the corner

I was grateful for this essay published in the New York Times last week, just before National Suicide Prevention Week.   The author cites some important statistics, the most important of which is that physicians are more than twice as likely as non-physicians to commit suicide.  He also cites the suicidality data from a recent multi center study, which he mentions to the exclusion of the depression data in the same study, which showed a depression rate in trainees of over 20%, with the rate higher in medical students.  Subsequent work has shown an increased incidence of burnout among residents and fellows rather than depression, although burnout is higher in all levels of physician trainees than in population norms.

As surgeons, we tend to want to believe that we are different:  we’re somehow tougher, more immune to the qualities that make everyone else merely mortal. Perhaps that tendency itself is one of many causes behind a rate of suicidal ideation in surgeons that is nearly twice that of the general population (and the associated tendency to not seek help for burnout and depression).  We also seem to want to find a simple formula for self-care and personal wellness that can serve as a panacea for depression, burnout, and their associated consequences.  And while the truth is that self-care and wellness help, perfectionism and an easily-accessed sense of shame are drivers of many high-performers…and I will agree that surgeons are, as a group, high-performers.

If you know me well at a personal level, you know that I have been a HUGE fan of Brene Brown’s work on shame and authenticity for several years now.  Quite honestly, her work was life-changing for me because of the perspective it provided me on dysfunctional behaviors that I witness and dysfunctional behaviors I may have exhibited myself at some point.  Using that lens of shame, I was able to see how often we use it as a tool in education.  I was flabbergasted when we were doing our interviews for the disruptive surgeon study and several interviewees mentioned the tendency of disruptive surgeons to use shame as a “motivational technique.”

We have seen the enemy, and apparently it is us.

So, where do I propose that we go from here?

If you’re feeling burned out, if you’re able to recognize that you’re depressed, ask for help.  Find someone whom you trust, someone who you feel has “earned the right” to hear your story, and talk to them.  In hindsight, I’ve realized the value of a couple of my friendships during residency, both of which were sanity-savers, if not life-savers.  In particular, during my last two years of residency, my friend Katie and I would meet nightly to walk her dog on the Shoreline Trail. I probably can’t count the number of times as we talked when each of us thought “Wow!  I get that.  It’s happened to me too.”

If you see signs of depression or burnout in a colleague, offer to be that support.  Providing some empathy if they say, “I’m stuck, it’s dark, I’m overwhelmed!” might just make the difference.

Burnout and surgeons: We don’t like admitting it, but it’s real

Today will be my first “theme-based” blog.  Last Thursday I wrote about the challenges of ICU care and family conflict, and the implications that has for staff burnout on the ICU team.  Today?  I’m tackling that issue of burnout in surgeons.  It’s real, it’s prevalent, and it’s something we simply have to do better in both confessing and addressing.  For my readers, I am focusing on general surgeons today, recognizing that burnout does impact other surgical specialties and other medical specialties.  In the last 5 years enough literature has been generated on general surgeons alone that I wanted to focus on “my people,” as it were.

What I know about burnout from my personal experiences:

It’s awful.  I felt isolated, and I was certain that none of my colleagues could have ever possibly felt this physically and emotionally dreadful.  For me, it meant that a job that is truly a source of joy became a source of misery- I did not want to go in for the routine work, much less get called back in for anything.  I questioned anything and everything in my decision-making.  I talked myself out of my usual sources of stability (dinner with friends, running, yoga, reading fiction) because I foolishly thought that the martyrdom that might come with that deprivation would make things better.  I whined.  I self-medicated with food.  I contemplated who could take care of my cats if I moved to Alaska to be a river guide.  I was chronically pissed off, often short-tempered, and couldn’t understand why my life was so awful and how people would consciously sign up for this sort of misery.  If I had to summarize it in three emotions, I would go with exhaustion, shame, and fear.

What I know about burnout from observing colleagues and reading the literature:

Risk factors for burnout include being younger (which I believe is more a function of early-career, rather than chronologic age), having children, working more hours, being on call more, and working in an “eat what you kill” system.  Burnout increases medical and surgical errors, likely because we don’t have the cognitive bandwidth to use our best judgment.  Work-home conflicts heighten risk for burnout, and because in our society the burden of balancing work and home still falls disproportionately on women, this risk impacts female surgeons more than their male colleagues.  Oh, and residents aren’t immune.  I’ll confess that the worst burnout of my career was the last 6 months of my general surgery training when two colleagues were out on maternity leave and another was out interviewing for fellowships.  That business about work hours and being on call (and needing time off) is real, folks.  Trust me.

What we should be doing better:

The first step to addressing a problem is acknowledging it, right?  So, yes, we need to be honest about the fact that we do get burned out, and we need to admit it when we’re heading to that place or have arrived there (easier said than done in an ego-driven, indestructible lot like my colleagues).  As practicing surgeons, to care for ourselves and our future colleagues we need to model adaptive coping strategies and maintain a culture wherein surgeon well-being is encouraged.  We need to be honest with ourselves about how we’re  really doing, and if colleagues tell us we’re not doing so well, we should listen.  We should participate in fitness activities, find meaning in our work, and maintain a sense of gratitude (and therefore, by proxy, maintain a positive outlook).  Yes, that means that sometimes we need to flip the switch on being a surgeon and just be a mortal for a bit.

What has saved me:

  • Walks with my dog.  She finds so much joy in each moment that if I’m paying attention I can’t help but go along with her happiness.
  • Being creative.  For me this means writing (reasonably well) and painting and drawing (pretty poorly).
  • Yoga.  Do you know how hard it is to just SIT STILL and be with your body for 75 or 90 minutes?  It’s really hard!  It’s also really good for me because I can’t focus on anything else during that time.
  • My friends and family, and many of my coworkers.  They call me on it when I’m out of line.  They bring me chocolate when it’s a bad day.  They give me hugs when I need them most. They remind me that I’m doing good things and making a difference when I forget that I am.  In short, they love me when I feel like I least deserve it.
  • Being grateful for three things every single day.  Some days those things are pretty silly sounding because I’m struggling to find anything at all.  But, as Brené Brown reminds us, gratitude is at the core of joy.

What have your burnout experiences been, and how have you dealt with them?  More importantly, what keeps you from getting there?  Please share with me so I can learn, share with the other readers so they can get ideas.

I’ll close with a thank you.  This blog has been in existence for just shy of a month.  I am over 1000 views- and with lots of positive feedback- from you, my readers.  Thanks for reading, thanks for thinking, and thanks for being part of my journey.  I am grateful for you.