I Happened to Be Standing
I don't know where prayers go, or what they do. Do cats pray, while they sleep half-asleep in the sun? Does the opossum pray as it crosses the street? The sunflowers? The old black oak growing older every year? I know I can walk through the world, along the shore or under the trees, with my mind filled with things of little importance, in full self-attendance. A condition I can't really call being alive Is a prayer a gift, or a petition, or does it matter? The sunflowers blaze, maybe that's their way. Maybe the cats are sound asleep. Maybe not. While I was thinking this I happened to be standing just outside my door, with my notebook open, which is the way I begin every morning. Then a wren in the privet began to sing. He was positively drenched in enthusiasm, I don't know why. And yet, why not. I wouldn't persuade you from whatever you believe or whatever you don't. That's your business. But I thought, of the wren's singing, what could this be if it isn't a prayer? So I just listened, my pen in the air.
I just taught two of my residents an easy way to log cases without stickers, notebooks, cards (or any other HIPPA risky methods). They were all but jumping up and down with happiness, so I decided this might be worth sharing.
(For those that aren’t in medicine, this is a requirement for everyone training in a procedural based field in medicine.)
Step 1:At the end of the case, when you open the computer for the orders and notes, highlight and copy the patient info at the top of the screen.
Step 2: Open your Outlook calendar. Every institution gives you an Outlook account for your email and (even if you haven’t found it yet) this has a calendar, too. Hospital and medical school Outlook accounts are password protected and HIPPA compliant. (It would be a good idea to double check at your institution, but I haven’t found one yet where this isn’t true).
Step 3: Create an “appointment” for your case.
Paste what you copied from Epic into the “note” portion of the appointment. It will look like the green box in the image below.
Copy the name and MRN to the subject line of the “appointment”
Add the attending’s name if it’s not in the info copied from Epic.
Step 4: To officially log your case, open the ACGME site in a window next to your open calendar. Copy and paste the information from your calendar to log the case (isn’t that better than typing all that info?!?!…. you’re welcome!)
Step 4b: Put an asterix by the patients name in your calendar entry to show that you logged this case.
Hope that helps! If you discover any important tricks or shortcuts to add to this system, please contact me or comment below!
Like most of you, my New Years resolutions in past years have been something like “Exercise every day” or “Eat fruits and vegetables with every meal.” And, I bet that you had the same experience I did… a few weeks of “success” and then they seemed to fade away. The problem with these kinds of goals are how they are structured. They end up being “either-or” goals … you are either able to do them or, more often, you miss a day (or two… or three) and feel like a failure.
It’s a simple, but very powerful concept. Set your goal as a destination… as a “lighthouse” in the distance, and then head in that direction every day. As Ryder Carroll explains, “When goals are lighthouses, success is defined by simply showing up, by daily progress no matter how big or small…”
So instead of the usual New Year’s Resolutions, pick a few “lighthouse goals”. Write them down and keep track of how you are doing (every journey needs a map). This can be as simple as one piece of paper for each goal, but I am such a fan of the Bullet Journal, I hope you consider using it.
When you get up every morning think about how to move towards your goal(s). If you veer off course, that’s part of the journey…. look up, find your lighthouse, and correct your course. Every once in a while (maybe monthly?), look at the progress you’ve made and celebrate it! If, on the other hand, the goals you originally chose don’t make sense for you any more, pick some new goals, draw a new map and start over.
Potential New Year “Lighthouse” goals
- Learn more about compassion and practice it
- Be a better friend
- Write genuine thank you notes to people who have helped me
- Become more fit
- Eat real food for as many meals a week as I can
- Find out more about who I really am through meditation
- Keep a “stop doing” list
- Be better at my work through deliberate practice (practicing and learning the things I don’t like and aren’t good at until I’m better)
- Stay organized so I don’t waste time (and end up focusing on trivial things instead of what’s really important)
- Read things that bring me joy
- Learn about and use a Bullet Journal
- Find a community to support me
- Learn the names of as many people at work as I can
- Take the stairs as often as I can
- Make my living spaces enjoyable spaces
- Keep a journal to remember milestones and work out struggles
- Get good sleep as often as possible
- Learn Spanish (or any new language)
- Be on time
- Remember people’s birthdays and send a card
- Start the day with intention
- Appropriately limit email and social media time
Every year I try to post gift suggestions for the family and friends of people in medicine (and all other busy professions). Here are this year’s suggestions!
Listen. A great friend of mine told me once that human beings heal by telling stories. There are lots of stories in medicine that go untold, but I promise you there are stories. Listen mindfully, without judgment and without trying to “fix” anything. Start with “Tell me a story about something that amazed you”… and then take it from there.
Write a letter. Write a “letter of recommendation”. Yes, I’m serious! Not a letter to “get” or be elected to anything, but a letter that shows you know who they really are and how amazing it is that they have dedicated themselves to something so important. Make it a love letter, a letter of support, a letter with family history to encourage them… but a real letter. Write it on a computer and then print it, or use some beautiful stationary and a pen, but create a physical letter that will sit on their desk. Put the letter in a special box (something you might add to from time to time with other short letters?).
Instant Pot. There are kitchen conveniences, there are fads, and then there is the Instant Pot. This has taken on almost cult like status among users for a reason. It’s a 6 in one device (pressure cooker, slow cooker, rice cooker, saute, steamer and warmer) that makes it easy to cook healthy food. For students and residents, the 6 quart basic Instant Pot does everything you need it to do, but feel free to choose one with more bells and whistles if you want.
A cleaning service. No one likes to clean toilets. And, if you are working 80 hours a week, housework takes away precious personal time to socialize, exercise or restore your batteries in other ways. If you are in a position to do so, see if you can make this a win-win by working with a church, refugee placement group or another social justice group to find someone specific who really needs this kind of work. Whether it’s a one time “deep clean”, a monthly clean, or weekly cleaning and laundry, any help will be a deeply appreciated gift. Another approach is to do a little “sneaky” homework – your loved one may have a friend who has already found someone wonderful who might need more work.
The Gift of Organization. I have become a huge fan of the Bullet Journal. It is incredibly easy, very versatile and, I believe, a perfect system for medical students, residents and docs. (especially when paired with a list on your smart phone when you are separate from your Bullet Journal). Choose a good Moleskin journal and the new book by Ryder Carroll, who developed this technique, and wrap them together as a perfect gift. If you want to really make their day, include a package of good (but not too expensive) pens.
A gym membership (and other related gifts). It’s really hard to find time to exercise if you are busy, but it’s critical for mental and physical health. There are a lot of options here, but they need to be specific to the likes and dislikes of your loved one. If they are a runner, maybe a gift certificate for new shoes? Do they like spin classes? If so, check out where the good classes are near them. Same for yoga, dance, ice skating, tennis, swimming, etc. A membership at a YMCA ( if there is one near them) will give them access to weights, classes and often a pool. Would they commute to school/work if they had a good bicycle? Can you get them a new watch or fitness monitor that will help count steps and flights of stairs? Would an “on the go” exercise kithelp them?
A Meditation App. I tell my students that if they can only pick one thing on the self-care list to choose, that this would be it. There are plenty of data that show the stress-reducing benefits of meditation. What is amazing is that if you have a meditation practice the other self-care is easier, too. This is a great tool to help meet the goal to be better and happier physicians.
Your time.Can you cook some meals once a month and put them in their freezer? Do laundry? Bake cookies and mail them? Get their car washed every once in a while? Make an elaborate certificate with something you could do for them and wrap it as a present?
Tomorrow is Thanksgiving, so today I’m with my family, looking at the timeline for tomorrow and discussing when the pies need to go in, who is making the cornbread and calculating how long the turkey needs to cook.
As of today, there will be 12,996 families in the United States who lost a family member to gun violence in 2018…. almost 13,000 Thanksgiving tables with an empty seat from a preventable death – from this year alone.
Late at night on November 7th, the NRA posted this on Twitter:
My second tweet was followed by a long thread of PubMed abstracts with research results showing how we might start decreasing deaths from gun violence. The NRA, interestingly, removed all of those Tweets from their timeline.
#ThisIsOurLane has become a movement. A callous Tweet from the NRA started it, but that’s not what is sustaining it now. As I discussed in this podcast, I think what the NRA did was make physicians realize that this “debate” is not about politics, it’s about lives… human lives… sisters, brothers, mothers, fathers, friends. It’s about our patients and, unfortunately, our colleagues. As a result of what has happened since November 7th, physicians have realized we need two things to move this forward: stories and data. Human beings are not swayed by debates, they are moved by stories. Good decisions can’t be made on emotions alone – we need data and that means research, and funds to do that research.
What you can do to help:
- Support important groups working to address gun violence as the public health problem it is. Donate today to Affirm (American Foundation for Firearm Injury Reduction in Medicine), Giffords, The Coalition to Stop Gun Violence, The Brady Campaign, Moms Demand Action for Gun Sense in America.
- Commit to questioning what you hear – from both sides. Question whether the fear created by the NRA is to serve another, more political aim… one that you might not completely understand or agree with. Ask questions. Ask for data. Recognize and ignore political rhetoric (from both sides). Keep an open mind.
- Support the funding of research into gun violence. Contact your representatives to let them know this a priority for you. This is no different than what we did as a society when we looked at death from car crashes… and developed seat belts, stronger cars frames and air bags. Wouldn’t it be great if we could see the same decrease in gun deaths through research?
- If you are in healthcare, tell the stories in a way that respects your patients and their rights… but tell them. If you are on social media, use that platform. Until people realize that these are our siblings, parents, colleagues, and not just statistics, we won’t make progress. We have to move hearts before we can move minds.
I am so thankful for my family, for the opportunity to gather at the Thanksgiving table together, and for the many friends and opportunities that have been given to me. My heart goes out to all families who have lost a loved one to gun violence, including the horrible loss of life by suicide. May you find some small solace in knowing that we are holding you in the light – and that we will continue to work hard to end the tragic epidemic of gun violence in our country.
I take care of non-conforming teens, but I have many colleagues who are “uncomfortable” with what they call the “new” issues of sexuality. I am convinced it’s because they don’t know the science, the vocabulary and how to speak to non-conforming teens.
This presentation was put together for my pediatric surgery colleagues as a project for a course I’m taking, but several of them asked me to make it more available so they could share it, which is why I’m posting it here.
Research has demonstrated that most aspects of sexuality are far from binary (either-or). We now understand that sex, gender, identity, expression and attraction are separate aspects of sexuality – and that they can be quite varied and fluid (i.e. can differ over time or in different situations).
Pediatric surgeons are among the professionals who care for babies who are born with ambiguous genitalia or, more correctly, what is known as “disorders of sexual development“. For pediatric surgeons, it’s been clear for a very long time that there are three categories for “sex” – male, female and intersex. Almost 2% of children are intersex (which, by the way is the same percentage as the number of people who have red hair).
Gender refers to the identity we hold as an individual. I love this particular diagram with “Barbie” on the left and “GI Joe” on the right. What a delight that we have people all along this spectrum! It’s also true that there may be days you are a 5 and other days your are an 8… whether your sex is male, female or intersex.
Because it’s such a spectrum, there are different ways to describe someone’s identity. This chart represents the most common words used. Cis-gender may or may not be familiar to you, because it is the correct way to describe what is usually (but sometimes not correctly) assumed – i.e. that a person’s gender is the same as their sex.
When we have patients, friends or colleagues who are non-conforming, it is our responsibility to address them in a way that affirms them as human beings. For those who have a clear gender identity (whether its cis-gender or transgender) it is fairly straight forward. When addressing non-binary folks, the correct pronouns to use are they/them/theirs. This is hard for most people because it’s new. It’s perfectly ok to tell them it’s hard but that you are going to try your best. The other important take home message is that if you aren’t sure, it’s ok to ask.
To add even more to the amazing diversity of human beings, how you express your gender is also completely separate from your sex and your gender identity! So, you can be born with female genitalia (sex = female), identify as a girl (cis-gender) but still choose a gender expression that is more typically “male” in terms of behavior and dress. Gender expression is also amazingly fluid, since there are other times this same individual may prefer to express as “Barbie”, somewhere in the middle, or “GI Joe”.
Although most people are familiar with bisexual, homosexual and heterosexual as concepts, the fact that there are people who are asexual may be a new concept to many.
The Genderbread person is a wonderful visual representation that sex, gender, expression and attraction can all be independent of each other.
So what prompted this presentation and now this blog post? Gender dysphoria is real, although not common, and it is a state of suffering. There is so much stigma in our society around sexuality that these children and young adults feel ostracized and isolated. As professionals who care for children and young adults, it is important that we understand these issues, learn to speak openly with patients and families experiencing the effects of gender dysphoria and refer them for appropriate medical and psychological care.
It’s hard to know what to say, but it’s so important to say it. Being open – even admitting that you don’t know much about sexual fluidity – is key. More importantly, caring enough to ask and learn may save a life.
Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!
Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive”
The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.
Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.
So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.
Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”
The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?
The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized? (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)
This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.
- SURVEY to get the big picture
- QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.
During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.
*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)
After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.
Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language. The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts. That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)
Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!
Did I already mention that you need to review?
This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph. First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.
Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later. More is better. Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!
Another thing about our brains and learning. Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.
Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.
People sitting next to you in your study areas are going to look like they have it more together than you do. It might be true… but it probably isn’t. If someone has a study technique that looks like it will work for you, by all means try it! Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,
Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.
Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.
It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.
I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.
Welcome to the best career in the world! We are all happy you are here!
Dr. Marc Rowe is one of the truly great pediatric surgeons of our era. His work in newborn physiology profoundly changed how babies were and are taken care of in intensive care units. His prolific research, along with the many people he trained, has unquestionably affected the lives of hundreds of thousands of newborns. He has taken on creative work as a writer and wood carver in his retirement. Dr. Rowe is one of my personal heroes and, when I read this essay he recently posted, I asked his permission to post it here to be able to share it with you.
I am troubled by what is happening to our Country. Principles and ideals – truth, honor, kindness, diversity compassion and love and protection for the people, the creatures and the environment we share has been replaced by selfishness, prejudice, lies and a willingness to compromise in order to gain material wealth and power. What is particularly frightening is the effect the current leadership may have on our greatest gift, our children- the message sent – that you can be dishonest, unfaithful to your loved ones, lie, be a racist, a bully and a braggart and still become the most powerful person in the world and be supported by many of our religious and political leaders. I am confused – does this mean that these political and religous leaders would choose our current president to be a role model for their children and grandchildren?
As I watched this sad period in the history of our country unfold I was overtaken with a sense of powerlessness. I then remembered two lessons I learned during my career as a pediatric surgeon. The first occurred during my first job as an assistant professor of surgery. I was incensed by an episode of academic politics and was tempted to speak out but realized if I did I would pay a price. I vented my frustration to my wise and famous boss, Dr. Mark Ravitch, a battle scarred warrior of the political and academic world. He said – “before Socrates drank the hemlock he began his defense by saying –never let it be said that I had a podium and failed to speak. – You have a big mouth use it”.
The second lesson came later when I became depressed realizing the huge number of children suffering from potentially correctable diseases and abnormalities and how little one person could do. I then began to think about the ripple effect – the ever-expanding effect that even one person can have by teaching and striving to be a role model. I realized that young people are astute observers and learn not by what their teachers say but by the way they act, how true they are to the principles they teach and most important by not selling out when being principled becomes painful and dangerous. Kids spot phonies a mile away.
Three people I have greatly admired, Mother Teresa, the Dalai Lama and Robert Kennedy all have spoken of the ripple effect. To quote Robert Kennedy who spoke of the ripple effect during the tumultuous civil rights strife – “Each time a man stands up for an ideal, or acts to improve the lot of others, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”
This carving I call the Ripple. The pond and thrower is carved from a branch and cross-section of bass wood, the shoreline is made from Sanibel sand and the stone in the pond is a small piece of river rock.
There is a longstanding superstition in medicine that you never wish someone a quiet call night, sort of the medical equivalent of never wishing an actor a good show. We are trained in science, so all physicians know this is silly…and yet…
There are many theories in psychology about why human beings are superstitious, but the one that I think best explains the superstitions of doctors is that superstitious rituals decrease stress and can improve performance during stressful work.