This past week I attended the Society for Critical Care Medicine Critical Care Congress.  Sure, the venue was a draw (Honolulu), as was the opportunity to spend time hanging out with my favorite pharmacist (Ann Marie is a rockstar and wonderful human). More importantly, I always leave this meeting feeling like it was time and money well spent.  This year was absolutely no exception (and yes, Burn Unit colleagues…be afraid.  I have at least 5 new and improved ideas for us!).

One of the standout sessions was a 2 hour discussion of burnout in ICU providers.  The session focused on physicians and nurses, and I’ll grant I would have liked more inclusion of information for our APCs, our PTs/OTs, and our pharmacists.  In spite of that, there was a lot of great discussion around the topic; if you want to see what it looked like on social media, check out the #StopICUBurnout hashtag on Twitter. It’s clear that we need to take a team-based approach to burnout because of the impact on team dynamics (it’s contagious) and patient outcomes (it’s negative).  Oh, and it also negatively effects our learners.

Here’s the conundrum around burnout.  A certain amount of stress can be positive and constructive under appropriate circumstances.  Plenty of  literature demonstrates that we adapt, both individually and collectively, with a certain amount of stress and that these changes can be for the better.  The issue becomes when the amount of stress is simply too much and we can’t manage another thing.

Like this:

I’ve been there, and if you’re honest with yourself you’ve probably been there too. That’s when stress can become negative and maladaptive and push us into that “burnout” space.

What if going for a run or going to yoga or doing whatever your “thing” is- what if that were actually helpful even when you’re heading into what I’ve referred to more than once as “the land of overwhelm”?  Or…to ask it another way, how many times have you not done something that you know is good for your mind, soul, and body because you simply have too many other things to do?

Again, yes, count me amongst the guilty. But what if that “one more thing” is actually something that really is regenerative for you?  It might actually help you to become more productive and more focused.  And if you’re a leader in your environment, by being authentic and engaged (and less stressed), you’re setting the best tone for your team to thrive as well.

Try it.  Let me know how it goes.  I promise I’ll work on doing better with this as well.

…and doggone it, people like me

Many of us remember laughing at Al Franken’s Stuart Smalley character on Saturday Night Live; for those who don’t remember the skit, the character is focused on repeating positive affirmations (and it’s still worth a watch).

I’m currently reading Appreciative Leadership, which I’ve am convinced may be the best leadership book I’ve read ever. The authors provide a framework for using appreciative inquiry as an approach to leadership.  The framework uses five “Is” for appreciative leadership: inquiry, illumination, inclusion, inspiration, and integrity. As I read the chapter on Illumination, I’ll admit I giggled thinking about a Stuart Smalley skit for a moment, then realized the actual value of positive self talk for generating what the authors call “positive power.”

If you think about when you’re at your absolute best, what thoughts are you having about yourself? Chances are that this is not when the word “loser” comes through your mind repeatedly, or when you’re wrestling with a case of impostor syndrome. Now, if you extend this to your team, what thoughts do you have when your team is performing at a crazy-amazing level? Again, I doubt that you’re thinking about how tired you are of Bob and Betty fighting, or what a poor lead nurse Billie Jo is.

Admit it- when you recall situations in which there was great success, you tend to go positive with the things you think about.  It immediately tells you what your and your team’s strengths are, and it gives you confidence to perform at a high level.

Time for a confessional: As I thought about using strengths and success oriented self-talk, I had a moment of self-illumination.  I realized that during the times when I have not been a good leader, when I’ve been petty and difficult, it has uniformly come from a place of insecurity. And what’s put me there? That little voice telling me that I’m not enough, that I don’t belong there, that I really can’t do this.

Additional confession, or wisdom grown from my own lack of it: If I’ve learned any lessons in the last decade, one of the biggest ones is that people “feel” that insecurity and that sort of inner monologue.  They know you’ve got doubts, and if you’re supposed to be leading them they’ll start to doubt themselves and the team too.  It becomes a vicious cycle.

That leader stands in stark contrast to the “I’ve got this, and we’ve got this” leader who instills confidence in the team, makes them more capable, and helps them to achieve at a higher level.

Which leader do you want to be? And what are you telling yourself about your ability to be that leader?


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.




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!

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!