Rethinking Institutional Metrics of Success

Recently, I was talking to a superstar surgeon who had travelled to Africa for two weeks to operate and teach. Lives were saved, a gift was given, but when he returned he was told that the two weeks he had spent in Africa resulted in not meeting his RVU target for the month…which he now had to “make up.”

Are you kidding? I can’t think of any physician that would think this is ok….

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I have held leadership roles and I am not naïve. “No margin, no mission” is a universal truth. Financial accountability and stability are necessary for us to heal patients, teach and change the future through research.   But, if we only measure and report productivity it will be the only metric that is perceived to matter…. and that’s not ok.

Financial and productivity metrics are critically important in any business. Healthcare is a very complicated business. But for physicians, medicine is a profession, not a business. This distinction explains why the standard business metrics of productivity don’t sit well with most physicians.

A stethoscope is on a balance sheet. Health care costs

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I’m becoming more and more convinced that we need to rethink how we define “success” for the physicians (professionals) who work in a business (healthcare). If we don’t, I’m afraid we will lose our way…. and potentially a generation of physicians.   So, as a starting point…. what if we thought about the following as potential new metrics of institutional “success”?

RVUs of the group, not the individual

It is human nature that what is counted is assumed to “count” the most. In addition to my friend who was almost despondent over having to “pay back” a mission trip that was part of his original contract, I have watched bright and hard-working physicians choose to stay to do one more little case or see two more consults instead of going home to their children because of this RVU pressure. By the way, these events were when a partner was on call and in the hospital, available and willing to take on this work.

Physicians are a competitive lot. If you give them a target to meet, they will do everything necessary to meet it. But the RVUs for an individual physician vary over time and with circumstances. Because medicine is a profession and not a “job”, there are very few physicians who are “slackers”.   Reporting the RVUs for individual physicians has the risk of hurting the morale of the physicians that are working hard, and rarely motivates people that don’t want to work hard. Besides, do we really want to send a report that monthly RVUs didn’t meet target to a physician who took time off to care for their own hospitalized child? (Yes, it happens.)

Let’s commit to a new institutional paradigm. Set RVU goals for the group. Trust the chiefs and chairs to be responsible for monitoring productivity. Let them take into account the normal ebbs and flows of work as a physican. Trust them to call in the few physicians who are consistently below expectations.

Turnover of physicians in the group

In an academic practice, it’s a good sign if strong, mid-level faculty members are recruited away to other institutions. In all groups there will be physicians who leave for family reasons or because a spouse has been recruited. But keeping track of physicians who leave for other reasons may be a metric that can reveal a bigger problem. Given the extraordinary cost of replacing physicians, isn’t this a metric that should be followed?

Burnout

Burnout is reported in 50% of physicians and costs institutions money. I strongly believe that every physician should have an assessment for burnout as part of their annual evaluation. Physicians that score high on the burnout scale need help – for their sake and the sake of the institution. The cost to the institution in decreased patient satisfaction and increased liability should be enough, but burnout is a life limiting or even life threatening condition. Let’s protect our most precious resource in medicine by paying attention to this epidemic. Why not reward divisions and/or groups that consistently demonstrate low levels of burnout? Why not use what they have learned to coach other groups who need help?

Support staff to physician ratio

I am quite certain that most people have no idea the amount of clerical work that physicians do today. For institutions, it’s a waste of extraordinarily profitable physician time and a major contributor to physician distress. No one knows what the ideal ratio of support staff to physicians should be, which support staff are more important, or what the differences should be between specialties.   So lets measure it, report this metric and compare between groups in our own hospitals and between institutions.  Let’s also make sure we understand how the ratio of support staff to physicians impacts burnout and physician turnover.

Teaching, research and innovation

Professionals work to make a difference but sometimes are not recognized for their successes. Even grown ups love a gold star.  Let’s make a big deal about teaching local physicians, publishing new research, receiving “Doc of the month” awards and building new programs. Celebrate successes – of all kinds – publically and sincerely.

Gifts of time

Likewise, let’s call out and celebrate the physicians who serve on boards of charitable organizations, who travel to treat patients and teach in underdeveloped areas, who sponsor student groups or who otherwise donate their time and expertise to make the world a better place.

Pay equity

I understand that salaries are “complex” in medicine, but it’s time to realize that they can be extremely unfair. When new physicians are hired at a higher salary than extremely successful physicians who have been there for 20 years, something is very wrong. When women and minorities consistently make less, something is very wrong.

There is no way that budgets can suddenly be changed to make pay equity a reality, but its time for all of us to make a commitment that pay equity will happen. Decide how long it will take … 5 years? 10 years? Once you have decided, let your physicians know you will commit to this change. To be transparent, report an annual metric of the percentage of physicians that meet the goal of pay equity. Make these changes. It’s the right thing to do.

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How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards.

Ok, now that I have your attention, let me share something with you. I’m going to show you how to maximize what you learn from the “school” we call rotations in medical school and residency so you can be an awesome master clinician. And, yes, it’s going to help you with your exams, so stay with me.

Clinical rotations are a strange blend of learning and work. You learn from the work, but we all forget that the work is not the purpose of these clinical experiences. The purpose of rotations is to be able to “practice” medicine (as a student) and then master the art of your specialty (as a resident.)

There are six basic principles to learn medicine, and then learn your specialty …and on the way ace the exams:

  1. Remember it’s school.
  2. At the beginning of each rotation, decide what topics you need to learn during the rotation and make a list.
  3. Take notes. All the time.
  4. Figure out how you will store your notes so you can find them quickly and organize them for review.
  5. Go through the notes you make every day to review them and then store them in your system.
  6. You can’t learn medicine from a review book (yes, including UWorld)

Somewhere around the beginning of my third year of residency, I was sitting in the “dome” (the chief resident’s “office” above OR 1 in our County Hospital) when Fred, one of my fellow 3rd years, walked in. He sat down and started to look through a stack of 3×5 cards so I asked him what he was doing. We all knew that he had scored the highest in our class on the ABSITE (the surgery in-service exam) and I was about to find out why.

REMEMBER IT’S SCHOOL

Fred figured out from day one that there was no way he was going to be able to study like he did in college and during basic sciences. Instead of hours to sit and read, it had to be flexible “on the job” learning.

This mindset is probably the single more important thing to cultivate. It’s the thing that drives you to constantly ask questions about why things are done the way they are and then go look up the answers.

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AT THE BEGINNING OF EACH ROTATION, DECIDE WHAT TOPICS YOU NEED TO LEARN DURING THE ROTATION AND MAKE A LIST. 

Your list can be pretty simple, or more complex, but it needs to be enough.

First hint – There is a curriculum that has been defined for your rotations. Everything your professors have decided should be taught should absolutely be on your list.   (By the way….If it’s in the curriculum, it has to be part of an objective. If there is an objective, it has to be linked to a test question)

Second hint – There is no way in medical school that “surgery” (or any specialty) can be covered in 8-12 lectures. The same is true for your rotations in residency. You have to do more.

This is one time that an example may be better than a formula. Let’s say I’m a brand new clinical student on my core surgery rotation….

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 Step 1. Find a textbook of Surgery and make a list of the topics from the chapters. A spreadsheet may be best for this, but any kind of list will do. 

For example, our library has Sabiston’s Textbook of Surgery (20th edition, 2017) on line:

 

 Step 2. Breathe deeply. There are 72 chapters and no, you are not going to read all these pages.

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Step 3. Create a schedule to SKIM every chapter during the rotation. Look only at the “big picture” i.e. headings, section titles, diagrams, tables. Your schedule should leave the last week or two free. So, for example, if your rotation is 2 months long, plan to SKIM 12 chapters a week to get them done in 6 weeks.

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 Step 4 – Now we get to the real deal (remember, this is graduate school and/or specialty training).

List the sections on your spreadsheet.

As a student, you won’t read every section – unless they are very general (Acute Abdomen, for example) or if you have a patient with that particular problem. Here’s what it might look like:

 

TAKE NOTES. ALL THE TIME.

After I learned Fred’s system, I always kept a stack of blank 3×5 cards in my pocket. Like him, for the last 3 years of my residency, I made notes ALL the time.  Here’s the kind of notes we are talking about:

  1. Reading textbooks or other curricular readings. Take the time to make the notes and make them well so you never have to go back to the chapter to review it.
  2. On rounds when someone teaches an important point (e.g. the 7 things that keep a fistula from closing)
  3. During Grand Rounds
  4. During conferences
  5. When you look up a paper to read about a patient
  6. And – most important – what you learn from specific patients. Do NOT put the name of the patient or their MRN (HIPPA). But, do put specifics that help you remember the patient (e.g. pt that always wore a red baseball cap and had a tattoo of a dragon)

As you can imagine, once I started this system, I was making 10-20 notes a day. It is remarkable how much you learn in a given day… and how it’s almost instantly gone if you don’t write it down.  In three years I filled up two boxes with cards. These cards were the only thing I reviewed for my Board exams.

 

FIGURE OUT HOW YOU WILL STORE YOUR NOTES SO YOU CAN FIND THEM QUICKLY AND ORGANIZE THEM FOR REVIEW

This is why using a notebook isn’t the best way to keep notes on rotations. You’ll take them chronologically and, unless you have an amazing index at the back with all the key words and pages listed, you’ll never be able to find a specific note.

The key is being able to “file” the notes so you can find them.  For the 3×5 system, leave a blank square at the top to put the topic you’ll use to file them.

I used anatomy as the basis for my filing system. So I would use a pencil (so I could change it later if I needed to) to put the topic in the box.  For example

Pancreas, pancreatitis

Appendix, neoplasms, carcinoid

This is very old-fashioned (but very effective) system.. I personally think there are better ways to do this now using scanning, cloud storage, key words and tags.  For some ideas, check out this post.

What doesn’t work well is to try to type notes on your phone.  What REALLY doesn’t work is to make notes and then decide to copy them, type them or somehow redo them later. (It never happens).

 

GO THROUGH THE NOTES YOU MAKE EVERY DAY TO REVIEW THEM AND THEN STORE THEM IN YOUR SYSTEM

The key to learning (as opposed to memorizing for a test) is review. Simply filing the cards means you are reviewing them. Plan to pull them out to look at them (and all the work you accomplished!) every week or two.

More importantly, when you see a patient with pancreatitis 5 months from now on a different rotation, pull the cards you made on this rotation. You’ll find you have 20 or so cards (or card equivalents) on pancreatitis … a review of the Surgery textbook, notes from Grand Rounds, the 3 patients you saw with pancreatitis that taught you about the disease and a few pearls you learned on rounds from your chief resident.

 

YOU CAN’T LEARN MEDICINE FROM A REVIEW BOOK (YES, INCLUDING UWORLD) 

I’m really serious. Not only will you suffer when you are taking care of patients, you won’t do as well on the tests (despite what the upper level students or residents tell you).

Remember the last two weeks of the rotation that you saved?  Now’s the time to pull out the review books.  It’s a wonderful way to review what you have learned from your skimming and patient oriented reading.  It’s also a great way to identify gaps and look up information.

p.s. Take more notes while you are doing this.

p.p.s Review all your notes, including the ones you make from the review books.

p.p.p.s Review them again.

Link to the Wikipedia article about the forgetting curve

We All Need a Compass

I was delighted to be asked to be the AOA visiting professor at the University of Miami Miller School of Medicine this week.  The following is the speech I gave at the induction banquet.  For those who are not in medicine, Alpha Omega Alpha is the “Phi Beta Kappa” of medical school, an honor society that recognizes students who are at the top of their class… but who have also demonstrated service, leadership and professionalism. 

 

What an honor that I have been asked to be here tonight for this celebration!  I am in the company of superstars and great friends, both new and old … what could be better?

I want to start by congratulating the junior AOA, resident and faculty inductees.  For the junior AOA inductees, you are clearly on a strong path to excellence which will serve you well.  Although I’m going to address my remarks to the graduating seniors, please know that I haven’t forgotten you or what it took for you to be here tonight.  For the resident and faculty inductees, you have been singled out for this very particular honor because you are amazing clinicians, educators and role models.  Thank you for what you do.

I thought I’d start with a short description of what it means to be inducted into AOA from the AOA website.

“Election to Alpha Omega Alpha is an honor signifying a lasting commitment to scholarship, leadership, professionalism, and service. A lifelong honor, membership in the society confers recognition for a physician’s dedication to the profession and art of healing.”

Induction into AOA is a major milestone in your career and, based on your predecessors in the organization, it also represents the beginning of a remarkable journey.  It’s a journey that you won’t take alone.  If history is a guide, you represent the future leaders of medicine, which means you’ll be guiding others on this journey as well.

That’s the reason I decided I should talk about how to use a compass.

 

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I suspect that you have all used a compass before but, like me, you probably haven’t given it much thought.  A traditional compass works by aligning a needle to the magnetic pulls of the north and south poles.  Although we really could use either north or south as a reference point, by convention we use north. I’m not going to get into the differences between true north and magnetic north*… suffice it to say that because a compass lets us know where north is, we can calculate the difference between “true north” and where we are heading, which in nautical terms, is called our “absolute bearing”.

So where am I going with this?  Why is it important to have a point of reference, a “true north”, as you start your journey through residency into the practice of medicine?

I know you’ve already been on services where the focus seemed to be more on checking the boxes on the scut list than on caring for the patients… and you had the feeling that there was something missing.

That’s why you need a “true north”.

You’ve also been on committees or in organizations that seemed to worry more about policies and procedures than how to use those policies and procedures for the better good.

That’s why you need a “true north.”

And I know that you have experienced days where you manifested one or more of the three cardinal symptoms of burnout, days when you lost enthusiasm for your work, felt that patients were objects rather than people and/or decided everyone around you could do a better job than you could.

That’s why you need a “true north”.

Unless you know where your “true north” is, you can’t navigate… you can’t make the adjustments that keep you on course.

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The single most important piece of advice I can give you as you start on this journey is to make sure you know where “true north” is for you.  As each of you define your own personal “true north”, you will share things in common.  For example, loving your family and friends, being kind, and trying to make a difference.  But even though there will be common themes, “true north” will be a little different for each of you.  This is not as abstract a concept as you might think. It is not only possible to articulate your goals, what gives you meaning and how you define your own integrity, it’s important to do so. And, yes, I mean write them down, think about them, and revise them when necessary.  When you hit the inevitable days of stormy weather, having a compass that it true is critically important.

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In reading about compasses, I also learned that the traditional compass has to be held level to work.  I learned that “when the compass is held level, the needle turns until, after a few seconds to allow oscillation to die out, it settles into its equilibrium orientation.”

What a great image.  You have to be still to let the compass equilibrate.  You have to be mindful to look at the needle to calculate your absolute bearing.  And then you have to take that information and apply it to correct your course.  And to do so, you have to hold the compass level, which I think is a great metaphor for taking care of yourself – physically, emotionally and spiritually.

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There is not a lot in the day to day life of an intern, resident or practicing physician that teaches us the skill of focusing on that still point, on getting our bearings to make sure we don’t veer off course.

It’s not a trivial problem.  Veering off course can result in doing something we don’t want to do or, more importantly, becoming someone we don’t want to be.  More importantly for those of you just starting on this journey, a small error in navigation at the beginning of a journey results in a very large error when you arrive.  That’s why, as you start this journey, it’s so important to know what “true north” is for you.

As you articulate what your “true north” is, I would also urge you to translate it into something that is easy to remember for those times that you are making a decision in a difficult moment.   For me, my “true north” as a physician has been distilled into three rules that I try to follow and that I teach my trainees.

Rule 1:  Do what’s right for the patient.

Rule 2:  Look cool doing it.

Rule 3:  Don’t hurt anything that has a name.

Let me expand just a little…

Rule 1 means always do what’s right for the patient.  Even if you are tired, even if others disagree, even if you don’t get paid, even if it’s not technically “your” patient – do what’s right.  It also means developing an life-long method to deliberately read and study so you know the right thing to do.  And it means doing all of this with compassion and integrity.

Rule 2, “Look cool doing it”, means practicing your art until you look cool.  If you are surgeon, make sure your movements look like Tai Chi and that you have no wasted motion.  If you are a pathologist, learn all the variations on the themes that cells can create. No matter what your specialty, read about each of your patients, prepare for all cases, procedures and conferences deliberately and diligently. “Look cool doing it” also means don’t lose your cool.  Be professional, which at its core is just another way of saying kindness and integrity matter.

Rule 3, “Don’t hurt anything that has a name”, certainly means don’t cut the ureter if you are doing a colectomy, but it means more than that because…

You have a name.

Your significant other has a name.

Your institution, your friends, your family all have names.

You are about to embark on the amazing and challenging journey of residency… I know you have a sense of trepidation and also a sense of incredible excitement.  Everyone in this room who has been there remembers and, to be honest, is probably a little jealous. What an amazing time to start a career in medicine.

Congratulations on all you have accomplished so far. I wish you smooth sailing and a compass that is true.

 

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*Because I am using “true north” as a metaphor, the scientists will have to forgive me.  There is a difference between “true north”, which is the actual north pole and “magnetic north” which is what a compass shows.  Here’s a great link that explains this further:  Magnetic North vs Geographic (True) North Pole

 

 

 

Sometimes it hurts…

A few years after I started as an attending in pediatric surgery, I was called to see a little girl who had been with her father at a construction site. For whatever reason, a wall under construction had fallen and she was caught under it. Her injuries were severe, with massive blood loss from a crushed liver. We opened her chest, packed the liver, transfused her massively but to no avail…

I vividly remember what happened next. Instead of the usual quiet moment of reflection, the team started talking about our week, carrying on a conversation as though this was just one more event in a busy day. It hit me how unusual this was as I was driving home. It was the middle of the night and, as I drove into my neighborhood, I noticed that I wasn’t feeling anything, that the sadness and other emotions I usually felt when I lost a patient weren’t there.

A cat darted in front of my car. I got out of the car, looked at the cat and burst into sobs… which continued for a good 30-40 minutes.

The loss of a patient, the loss of a pet, or even the loss of a dream related to your career leads to grief. Granted, the depth of grief may be, and should be, less than the loss of a family member, but it is grief nonetheless.   Because these losses are often viewed as “less serious”, people may feel that it’s somehow “not normal” to feel true grief when they occur. This is particularly true for physicians, who often have to suppress these feelings to be able to treat the next patient.

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Here’s the single most important message…It’s ok to feel the loss.

The ability to cry over a tragic injury or loss of a patient is the sign of a compassionate physician or provider, not a sign of weakness.   For all of us who experience these losses, It is important to allow ourselves to grieve, if that is what we are feeling. Although this will mean different things for different people, here are a few ways that might help…

Share your thoughts with someone you trust. Talk to your friends and, in particular, senior colleagues.   It is important for your future patients that you are allowed the space to grieve. It is also normal to worry about returning to work if you’ve experienced a particularly traumatic loss.  If you have a colleague who has lost a patient, let them know in direct or indirect ways that you are there for them if they need to talk.

If you are the team leader, talk to your team. It’s important to debrief with your team (and anyone else who was there) immediately afterwards and a few days later.   Make sure you acknowledge how hard this is and ask if people are ok. Remember for many of your learners, this may be their first time to experience the loss of a patient… how you respond will be remembered as their example for the future.

“Good models teach us to handle the experiences that change us.” Thomas J. Krizek.

 Communicate with the family. Immediately afterwards, just be with them. It is human nature to avoid “bothering them” in their time of grief but try to go. Bearing witness to their grief by sitting silently with them is a powerful way to help. Write a condolence letter. Call, email or write a note 3-6 months later to let them know you are thinking of them and to ask if they have any lingering questions. Offer to meet with them if they would like.

Go to the visitation and/or the funeral. Even after a hard journey together, even if you question if you could have done something different, go to the funeral if it feels like you should. Not just for the family, who will be very appreciative – but for you. There is closure in ceremony for everyone.

Take care of yourself. Focus on self-care by being with family and friends, eating good food, exercising, sleeping and doing the things you love.   It is both the burden and privilege of our profession that we experience these moments of intense and tender transitions…. but sometimes it hurts.

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What we can learn from pain…

The following was sent to me after I reached out to a dear friend who had suffered rib fractures (and more) in a fall.  I was so touched by his perspective and the potential power of these words to heal  that I asked permission to post it here.

I’ll say the week started last Thursday, when I sucked it up and scheduled a host of delayed medical procedures, got blood drawn for an array of things, and planned a weekend of work plus my first attempt at cycling since surgery over two years ago – on the place the bike seat hits. I dislike medical tests because I hate to not make great scores on tests, and unlike other tests, it is hard to study for a cancer marker test or blood pressure test. But it was past time.

By Saturday, the weather was Springlike, and all I had to do before climbing on a bike was some roof leak patching. See earlier missives on Facebook about how THAT went. By Sunday I was pushing a morphine pump (almost without effect) wondering just how crushing my skeleton into pieces was going to be the big breakthrough I knew was spiritually on the way to this week. But not doubting the breakthrough at all.

I was too messed up to use even a cellphone, but the outpouring of love, compassion, caring, helpfulness, prayer, gratitude, and ICU humor was so huge I could feel it even through the opioid mist and, I am told, Olympic class pain. It continues even today.

Did you know that gratitude is one of most biologically and spiritually powerful “drugs” ever tested? It measurably switches genes on and off, by the thousands, but always in a good way. Well my gratitude graph is off the chart this week, starting with so many close friends and family. I have reconnected with several long loved dear souls, and connected with several new dear souls. If I had gotten on the bike, death or paralysis were likely outcomes, due to medication issues. If I hadn’t been in ICU, several hidden medical issues would not have been detected.

My beloved wife has almost slipped up a couple of times this week and let her secret wings show. I believe the modern definition of marriage encompasses humans marrying Angels, so I can still call her “wife”.

Then we get to medical tests. Cancer markers – none, again. Extensive CT scans necessitated by my air cargo disaster – no sign of cancer etc. Vertebrae, spinal or brain damage, or chances of dying of testicular cancer? Approaching insignificant. Crickey, my body acted like a crumple zone protected Volvo. Major systems were cushioned by minor (numerous and very painful) fractures.

Medical issues? Of course. But the extensive testing and freak accident have revealed reversible issues, including ones caused by my medications, which would not have been detected in the ordinary course of things. Issues that might have been lethal if I hadn’t gone to ICU and smart people put the puzzle together.

Closer than ever to my wife. Reconnecting with dear friends of all ages. Making new friends. Confirming that my former cancer is truly leaving the building. Re-prioritizing work, play, health, etc. And remembering that the only shortages of Love in this Universe are from people kinking the hoses. We could never use the actual, Infinite, supply. As I write this, I prepare to go hang with beautiful souls tomorrow and share some healing. Pain is just the contrast needed to highlight the transcendent, joyous, beautiful, loving ride we call Life. Since I really should be dead or paralyzed right now, every breathtaking twinge is a reminder to be grateful. Easy peasy.

I had to postpone an appointment with an old, wise, preacher I have known since childhood. I was talking to him on the phone about the combination of joy, gratitude, pleasure, humor and serious pain, and he said he would quote one of his old buddies who is used to suffering. He says”Hallelujah anyway”. I hurt myself laughing at that one, so, just “Hallelujah ya’ll!” Sums it up for me.

Peace, Love, Joy.

They are choices.

Ouch, anyway.😘

New Year Resolutions

The “clean slate” of a new year almost always leads us to think of resolutions … things we could change to make our lives better.  This is a great time for reflection to realize what you have accomplished, where you’d like to be in a year, and what changes you need to arrive at that goal.  I just finished reading Making Habits, Breaking Habits: Why We Do Things, Why We Don’t, and How to Make Any Change Stick by Jeremy Dean which provided some useful ideas about making resolutions.

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Know why you want to make the change

“There has to be an ultimate goal that is really worth achieving or the habit will be almost impossible to ingrain.”  Jeremy Dean

Let’s take one example – losing weight.  It’s fine to say you want to lose weight… but why?  Wanting to fit into your clothes is not a trivial reason, but will it really motivate you when it gets tough as much as these?

  • Being able to “walk the walk” when you talk to patients about losing weight
  • Reduction in your risk for diabetes, heart disease, cancer and a variety of other health problems
  • More energy, better mood, less pain…

What’s important is that you find reasons that resonate for you.  Do a little research and write down why you want to make the change.  Plan to review this, and revise it when needed, on a regular basis.

 

Make the resolution then make a plan.

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To continue the losing weight example, what are the specific new habits you want to develop?  Are they “SMART” changes?   (Specific, Measurable, Attainable, Realistic and Time-Based).  For example…

  • I will eat 8 servings of fruits and vegetables every day.
  • I will set the alarm clock 15 minutes early to do push-ups, crunches and squats before I go to the hospital.
  • I will plan my meals and shop once a week so I can take healthy food with me to work.
  • I will schedule my workouts every weekend so I can attend at least two spin classes a week.
  • I will cook one healthy dish on the weekend that I can eat for at least 4 meals during the week

 

Develop the “what if” plan.

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The next step is to imagine all the things that might derail you and write down a specific plan for each of them.  This will be an ongoing process… as you come up with new excuses to not follow through with your new habit, add it to the list.

Back to the example of losing weight….

  • If I forget to bring fruit/veggies with me to work, I will go to the cafeteria or lounge to get at least 2 servings to eat at work.
  • If I walk by MacDonald’s and feel drawn in by the smell of the fries, I will remember that I’m trying to set a good example for my patients
  • If I hit snooze on my alarm clock, I will move it across the room.
  • If I think I’m too tired to go shopping for the week, I will remember that this is the key to having healthy food at work.

“Making healthy habits should be a voyage of discovery.” Jeremy Dean

 

Keep track.

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Self-monitoring is critically important to maintaining a new habit.   It doesn’t matter if you use an app like My Fitness Pal, a calendar, a spreadsheet or a system like the Bullet Journal… stay accountable by keeping track.

 

As the habit becomes engrained, change it a little to keep it interesting.

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Working out with exactly the same routine quickly becomes boring. It’s one of the reasons people love group classes like spin classes  – the instructors are always changing the routine.  Be mindful and creative… but stay out of ruts!

“Making or breaking a habit is really just the start. To develop a truly fulfilling and satisfying happy habit, it’s about more than just repetition and maintenance; it’s about finding ways to continually adjust and tweak habits to keep them new; to avoid mind wandering and the less pleasurable emotional states that accompany it. There is great enjoyment to be had in these small changes to routines. When life is the same every day, it gets boring.”  Jeremy Deans

 

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Looking for inspiration?  Here’s a list of New Year’s Resolutions for medical students, residents and busy docs.  Pick 1 or 2 and start working on your plan, your what-ifs and how you will monitor them!

  1. Learn to meditate and spend at least 10 minutes every day meditating with HeadSpace. (Here’s the TED talk that introduced me to this great app.)
  2. Eat fruits and veggies with every meal.
  3. Walk 10,000 steps per day.
  4. Take the stairs instead of the elevators.
  5. Learn the names of all the people you work with… the guy who mops the floor, the clerk at the desk, the person who works in the blood bank.
  6. Write down three things you are grateful for every night before you go to bed.
  7. Log all cases (if this applies to you) the same day and finish medical records within 24 hours.
  8. Use a system like the Bullet Journal or Remember The Milk to become more organized and never miss a deadline (including the birthdays of your family and friends)
  9. Cook your own meals at home (take a class if you need to).
  10. Be on time to conferences, rounding, meetings, classes, etc.
  11. Spend at least half a day a week “unplugged” and use it to play.
  12. Keep a journal to remember the important events of the day, vent about things that upset you, and make plans for the future.
  13. Read something that is not medical every day.
  14. Stop eating fast food.
  15. Drink less alcohol or stop all together.
  16. Get at least 7 hours of sleep any night you are not on call. (and have a plan post call to sleep more)
  17. Cut out all added sugar.
  18. Drink more water.
  19. Keep your house neater… or at least a part of your house!
  20. Stop texting while driving.
  21. Learn about motivational interviewing to help your patients.
  22. Read a major textbook in your field in one year.
  23. Learn something new from every patient you see
  24. Try a new way to exercise every month
  25. Set your intention for the day every morning.
  26. Eat breakfast every morning.
  27. Set limits on checking email, Facebook, Twitter, Instagram and other social media sites.
  28. Practice mindfulness.
  29. Plan your meals for the week on the weekend to make sure you have great food on call and at work.
  30. If you have to sit a lot at work, come up with a plan to not be so sedentary.

 

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Getting Organized:  The Bullet Journal

I’m a huge fan of using technology to organize my “to-do” list.  I’ve used (and loved)  Remember the Milk and Evernote as the backbone of my system.  But I recently discovered a simple, non-tech method which is proving to be the most effective tool I’ve used.

The Bullet List was designed by Ryder Carroll, who is a digital product designer.  The system is elegant, simple and requires only a blank notebook to get started.  (Although I adapted the system to use in Evernote to make it at least somewhat digital … and to avoid the inevitable crisis for an absent-minded person of losing the notebook!).

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The Bullet Journal is based on these five “sections” of the journal:

  • The Index – to know where things are in your notebook
  • Future log – to list big events for future months (ex: Plans for interviews for residency/job, rotation schedules, reading plan
  • Monthly log – a combination of tasks and events for the month (ex: reading plan to prepare for residency inservice exams)
  • Daily log – tasks, events, and notes for the day
  • Collections – list of things, for example books to read, track a goal (like exercise or sleep), technical points as you learn a procedure, or a gratitude log

Here’s the overview video from the site bulletjournal.com, which in 4 minutes explains the how to use a Bullet Journal.

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In addition to making sure you don’t miss important deadlines and events, the Bullet Journal also serves as an actual journal to help you remember important events.  For example, one of my entries last year was…  “Took residents to watch patient take first sip after Heller myotomy.  Everyone cried.”  Don’t underestimate the healing power of journaling during medical school, residency or after your training.  Recording these small moments will help, but using them as prompts for writing the story of your day can be even more powerful.

p.s. If you are in anyway an artist a) I’m jealous and b) have fun!

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Making a Bullet Journal Work in Residency from The Deliberate Doctor

Visual Bullet Journal from dxmedstudent.tumblr.com

How to Bullet Journal from thelazygeniuscollective.com