Lamentation for the Lost

Like so many others, I can’t believe the hatred and evil that has manifested itself in Orlando, Louisiana, Minnesota, Dallas, Nice and Baton Rouge.  I grieve with the families and friends of those who lost their lives. I embrace those who are devoting themselves to healing this hatred and the wounds it has caused.

As someone who teaches embryology I can tell you that all of us – no matter what race, religion, sexual orientation, or gender are fearfully and wonderfully made. We all start as one cell and become human beings through an amazing dance of cells that become eyes to see, hearts to beat, arms to hold and brains to understand and love. There are no differences between us until we are born and labels are applied.

As a surgeon, I can tell you that all blood is red.  I also can assure you that all hearts break equally when faced with hatred, loss or grief …. and all souls soar with birth, healing and love.

May we all become healers in this time of sorrow.

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My New Favorite Recipe – Quiche With a Healthy Crust!

It’s not often I share a single recipe, but this one is so delicious, so healthy and so easy that it warrants a separate post.

sweet potatoe quiche

Photo credit (and recipe)

Although the recipe as written has spinach filling, you can use other fillings. Just to give you a few ideas…

  • Sausage (regular or vegetarian), bottled red peppers, cheddar cheese
  • Canned artichoke hearts with parmesan cheese
  • Ham with Swiss cheese
  • Fresh tomatoes, mozzarella and basil
  • Any leftover veggies and/or meat in your refrigerator

This “quiche” makes a great dinner, but can also be put in your bag for breakfast or lunch for a busy day or call night. Quiche freezes well, so you can make several, freeze them and have breakfast/lunch/dinner for days!

 

What Big Magic Can Teach Those Who Serve

“Do what you love to do, and do it with both seriousness and lightness.”*

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On the flight home yesterday I finished Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert (She’s probably known to you for her NY Times Best Seller Eat, Pray, Love). For me, one of the overarching messages of her book was this – When you see what you do as your vocation (from Latin vocātiō, meaning “a call or summons”), and not just your job, it will transform how you view your work – a concept which I believe may be necessary (but not sufficient) to treat or prevent burnout.

As I read her thoughts on how to live a creative life, I realized that there were other ideas  that applied to physicians, physicians in training and others who serve:

 

Just show up. Every day.

“Most of my writing life consists of nothing more than unglamorous, disciplined labor. I sit at my desk and I work like a farmer, and that’s how it gets done. Most of it is not fairy dust in the least”

Learning and practicing medicine (or any other field) means showing up – really showing up – every day. Everyone in the first year of medical school learns that it is different than college. Cramming for exams is not only ineffective, it’s just wrong. You are no longer studying for a grade on a test…. it’s now about the patients you will take care of in the future. The same holds true during residency and when you begin your practice. It’s not just when you are a trainee.  Part of the “work” of medicine remains “unglamorous, disciplined labor”… keeping up with the literature, going to teaching conferences when you could be doing something else, finishing your hospital charts, being on call.

But the work of medicine is also about showing up every day in another sense, too – truly showing up for the people who rely on you – no matter what. That, too, can be “unglamorous, disciplined labor” when you are tired or stressed.

“Work with all your heart, because—I promise—if you show up for your work day after day after day after day, you just might get lucky enough some random morning to burst right into bloom.”

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They are your patients… from the first day of medical school until you retire.

Most of all, there is this truth: No matter how great your teachers may be, and no matter how esteemed your academy’s reputation, eventually you will have to do the work by yourself. Eventually, the teachers won’t be there anymore. The walls of the school will fall away, and you’ll be on your own. The hours that you will then put into practice, study, auditions, and creation will be entirely up to you. The sooner and more passionately you get married to this idea—that it is ultimately entirely up to you—the better off you’ll be.”

Caring for others gives us joy but also gives us the responsibility to know the best thing to do for them. Whether you are a first year student, 3rd year resident or a PGY35 attending, we are all still learning. “Life long learning” is not just a phrase, it’s the reality of what we do.

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It’s called the practice of medicine for a reason.

“It’s a simple and generous rule of life that whatever you practice, you will improve at.”

Learn the art of deliberate practice early. Deliberate practice, to use a musical analogy I learned in Cal Newton’s fantastic book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, doesn’t mean playing the piece from start to finish 20 times in an hour. It means spending 55 minutes on the small section that you struggle with, repeating it 100 times before you play the piece through once. It means instead of reading the comfortable material on the anatomy of the kidney, you deliberately tackle how the nephron works. It means that instead of doing the computer-simulated cholecystectomy 10 times you spend an hour tying intracorporeal knots in the trainer. Find the thing that is not easy and practice it over and over until it becomes easy.

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There is Peril in Perfectionism

“There are only so many hours in a day, after all. There are only so many days in a year, only so many years in a life. You do what you can do, as competently as possible within a reasonable time frame, and then you let it go.”

One of the greatest attributes of those who care for others is their devotion to the people they serve. But perfectionism, taken to its extreme, is dangerous. Extending your time to study for Step 1 beyond what is reasonable to try to get a higher score, revisiting decisions about patient care to the point of anxiety, worrying that your GPA has to be perfect are all counterproductive. The motivation to do well is like a cardiac sarcomere – a little worry will make you more effective, but stretched too far, there won’t be any output at all.

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Curiosity can overcome fear.

“No, when I refer to “creative living,” I am speaking more broadly. I’m talking about living a life that is driven more strongly by curiosity than by fear.”

It’s something most students don’t realize, but no matter how long you practice medicine, there are days when you are afraid. It takes courage to do what we do. Remember, being courageous is not an absence of fear, it’s being able to do what’s right despite the fear. I agree complete with Elizabeth Gilbert that curiosity helps. When you have something that doesn’t go the way you expect or frightens you, instead of beating yourself up (“I should have studied more”….”I could have made a different decision”…etc…etc) become curious. If you are thinking about a complication, commit to finding everything you can about the procedure and how to prevent complications. If you didn’t do as well on your test as you thought you should, look up different techniques to study, take notes, and remember information, and go back to make sure you really understood what was being tested.

Even more powerful than curiosity is gratitude. Fear and gratitude cannot exist at the same moment. Try it – the next time you are about to snap because your EMR freezes be grateful that you can see the computer, be grateful you have work, be grateful you have been trained to help other human beings …and see what happens.

“We must have the stubbornness to accept our gladness in the ruthless furnace of this world.”

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Your worth is not the same as your “success”.

“You can measure your worth by your dedication to your path, not by your successes or failures.”

Wow…. This one is so important.

It’s not what you make on Step 1. It’s not how many cases you do, how many patients you see or how much money you make. This concept is taught by every religion and philosopher I know – for a reason. Be devoted to doing the best you can and to forgiving yourself (and learning from it) when you fall short.

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One last thing….for medical students trying to choose a specialty – forget about finding your passion.

This is a little longer quote than the others, and mirrors a similar message in So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love .

Find something, even a little tiny thing, that makes you curious (or fills you with wonder) and follow it. Dedicate yourself to following that curiosity and it will likely lead you to your career.

“May I also urge you to forget about passion? Perhaps you are surprised to hear this from me, but I am somewhat against passion. Or at least, I am against the preaching of passion. I don’t believe in telling people, “All you need to do is to follow your passion, and everything will be fine.” I think this can be an unhelpful and even cruel suggestion at times. First of all, it can be an unnecessary piece of advice, because if someone has a clear passion, odds are they’re already following it and they don’t need anyone to tell them to pursue it…..I believe that curiosity is the secret. Curiosity is the truth and the way of creative living. Curiosity is the alpha and the omega, the beginning and the end. Furthermore, curiosity is accessible to everyone…..In fact, curiosity only ever asks one simple question: “Is there anything you’re interested in?” Anything? Even a tiny bit? No matter how mundane or small?….But in that moment, if you can pause and identify even one tiny speck of interest in something, then curiosity will ask you to turn your head a quarter of an inch and look at the thing a wee bit closer. Do it. It’s a clue. It might seem like nothing, but it’s a clue. Follow that clue. Trust it. See where curiosity will lead you next. Then follow the next clue, and the next, and the next. Remember, it doesn’t have to be a voice in the desert; it’s just a harmless little scavenger hunt. Following that scavenger hunt of curiosity can lead you to amazing, unexpected places. It may even eventually lead you to your passion—albeit through a strange, untraceable passageway of back alleys, underground caves, and secret doors.

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*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!

 

 

Residency Applications: The Curriculum Vitae

Other than the personal statement, there is nothing more distressing to medical students applying for a residency than putting together a Curriculum Vitae (CV).

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So, what exactly is a CV?

 “The original Latin meaning of curriculum was a course, but of the kind that one runs around (it came from currere, to run).   Even more recent — dating from 1902 — is curriculum vitae, literally “the course of one’s life” (from World Wide Words)

Your curriculum vitae is a document that serves as a summary of what you have accomplished as a professional.

 

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What’s the difference between my CV and what I put on my ERAS application?

Your CV and what you put in ERAS differ in two important ways – the content and the format. ERAS will generate a CV from the information you enter, but it’s not in a format that is usually used for a professional CV.  In addition, the ERAS generated CV will not have the same information you will want on your CV.  For example, ERAS “experiences” don’t translate well into a professional CV.

 

Why do I need a CV in addition to what I put into ERAS?

  • You will need to give your CV to any faculty writing a letter of recommendation.
  • You may be asked to send a CV when applying for away electives.
  • It’s a good idea to take your CV with you on interviews to provide a copy to the program, especially if you have updated it since your application was submitted.
  • If and when you send emails to programs after you interview, it’s a good idea to attach your CV if it has changed at all. Bcc yourself when you do – if there is a problem with the email or the attachment, you’ll know it quickly.

 

What do I need to include in my CV and what should it look like?

There is no absolute “standard” format for a CV, both in content and in style, but there are some guidelines. In general, in addition to the “heading” with your name and contact information, the following sections (if they apply to you) should be included in the order they are listed.

  • Education (degrees, institutions)
  • +/- Place of Birth
  • +/- Citizenship
  • +/- Languages
  • Military service
  • Work experience (this is not summer jobs unless the pertain to your application i.e. don’t list being a waiter, etc!)
  • Volunteer experience (make sure it’s significant. There is no advantage to listing 20 things that all lasted a week or two …. again, unless it’s specifically related to your application… see “don’t pad your CV” below)
  • Other training (eg BLS, ACLS, special courses to learn a skill)
  • Professional memberships (including leadership positions, committees)
  • Honors and awards
  • Publications
  • Presentations
  • +/- Personal interests (drop after you match if you include it)

 

It’s a good idea to show your CV to mentors in your specialty to get their feedback since there can be subtle differences in CVs between specialties.

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What should I do to avoid common mistakes in creating my CV?

  • Pick one font and stick with it. (11 or 12 font and something really standard).
  • List items in each section in reverse chronology (most recent first)
  • Number your publications and presentations.
  • Leave plenty of “white space”
  • Don’t “pad” your CV with trivial events or accomplishments – it’s more important it’s accurate and appropriate than long.
  • Go ahead and list “hobbies and interests” as your last topic for the residency application, but remove it as soon as you match.
  • Double (no, triple) check spelling and formatting. Your CV is often the first impression a program will have.
  • NEVER put any designs, photos or logos on your CV.
  • If you put your personal email address, make sure it’s a professional email address. If it’s not, it’s time to get a new one.
  • Don’t EVER lie or exaggerate.

 

Where can I find examples or templates for my CV?

Many medical schools have examples on line and all schools have help in the Office of Student Affairs or through other faculty mentoring programs.  You can also sign into Careers in Medicine to see examples of CVs, which are also here.

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 What should I do with my CV after I match?

Remember, your curriculum vitae is a record your professional life… so it’s a “living” document that will need to be updated as new things happen. There is no one else who will every know exactly what you do and what’s really important more than you will. Keep a list somewhere of everything new that should go on your CV and sit down at least every month or so to review and update your CV. After residency when you “graduate” to having an assistant of your own, it’s still probably better to update your CV yourself. The AAMC provides a good example of a typical Faculty CV here which gives you an idea of what your future CV will look like!

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Overwhelmed by Email

“Email is both a miracle and a curse. At no other time in human history have we been able to exchange messages instantly globally; but at the same time, our ancestors didn’t spend hours each day sifting through memos, missives and newsletters we probably should just unsubscribe from.” Kadhim Shubber

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In the last few weeks, I have spent time counseling colleagues who had real issues after missing one or more critical emails.   I totally understand why… the volume of emails, and particularly of spam we all get is totally out of control. But the volume doesn’t really matter when you miss a critical deadline or, in the case of some medical students this year, an offer for a residency interview.

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Young man receiving tons of messages on laptop

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The key is to have a system – and to change the way you look at email. 

When you open an email message you only have three options and one of them is not to keep it in your inbox! Don’t use your inbox as a “to do” list – the emails will stack up and it becomes unmanageable.  The simple way to avoid this is to open each email message and immediately do one of three things:

  1. Delete it
  2. Answer it
  3. Create a task

Other important things to know about deleting (or not deleting)

Microsoft has recently introduced a new function for Outlook called Clutter.  It’s a good thing – as long as you know it is there and how it works!  In a nutshell, this function uses your behavior to decide if you want to see the email or if the email should automatically be sent to the “clutter” folder.  Beware – you need to either check the folder or disable this function, particularly at first.

The two other critical tools to help “debride” your email are to unsubscribe to emails you really don’t want to see, or block the sender (for true spam).  For other great tips, check out How to control your inbox from lifehacker.com and these tips from The Observer

Create a task? I am a big fan of Remember the Milk, but there are many other “to do” programs out there that would work, too. When I get an email that I need to turn into a task I send it to the “inbox” of my Remember The Milk account. Once it’s there, you then

  • Put it in a list (the four lists in my account are “Today”, “This week”, “Projects” and “Ideas”, but you can create any lists you want)
  • Give it a priority
  • Give it a due date
  • Set a reminder (if you need to)

Check your list! However you choose to make your task list, check it every evening to organize the next day’s tasks. This is critical to making this work. Don’t list 20 things either. Be realistic and put the top 3-5 things on this list!

Check your email! Check your email at least once a day, but not all the time… and NOT at your most mentally active time! For most people that means checking email in the afternoon or evening.

Change your mindset. Email is how professionals communicate, so we all have to learn how to handle our inbox without becoming frustrated or angry.

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I learned a very valuable approach from a friend one day when we were talking about email. I said there were times I just dreaded sitting down … and even got angry because of the volume of emails I have to answer. Her solution? Turn answering email into an exercise of gratitude. Be grateful that you have hands to type, eyes to see the screen, and the privilege of work..  As simple and potentially silly as this seems, it is a powerful tool to change how you look at answering emails. (p.s. it also works for the EMR!)

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Eating Well at Work

It’s hard for those that haven’t been there to understand how medical school, residency and/or long hours in the hospital changes what and how we eat.  There isn’t time to sit down to eat, there aren’t good choices and often, the only thing to eat is the “free” food at conferences.  But…. Free food isn’t free. There’s a reason it’s cheap (poor ingredients) and that it “tastes good” (lots of fat, sugar and salt)… but it makes us feel terrible after we eat it.  (Beware the middle of the night french fries!) More importantly, we aren’t providing the nutrients we need to take care of other people and ourselves.  So, what’s the answer?

Spend the money and the time to invest in your health! Grabbing donuts or bagels in the surgeons’ lounge in the morning, pizza at noon-day conference and a hamburger at MacDonald’s in the middle of the night is terrible. (You know it’s true).

 

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So what’s the alternative? Here’s a five-step, easy plan that will let you eat better, feel better and avoid gaining weight in medical school and residency.  This is predicated on cooking your own food but you can use this plan if you don’t cook by buying prepackaged foods.  But really…. If you can learn how to take out a gallbladder or care for ill patients in the ICU don’t you think you can learn how to sauté a few vegetables???

 

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  1. Make a plan
  2. Make a shopping list
  3. Shop once for the week and (when you can) prep ahead
  4. Use your day(s) off to cook things that might take a bit more time and freeze some for other days
  5. Keep a few “instant” healthy meals in your pantry

 

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Make a plan

Map out your week’s meals and snacks using the “pizza rule” (nothing you cook should take longer to cook than it takes to order a pizza). Pay special attention to call days. It’s important to have really delicious food which can be grabbed in a minute when you are on call. I use Evernote to make my list for the week so I can share it with my family:

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If you like to cook, you probably already know where to find recipes you’ll like. If you don’t cook regularly, I post recipes on @drmlb with #CallFood that meet the “pizza rule” and would be delicious on call. Here are few other sites I use regularly: Eating Well, Cooking LIght, My Recipes, Food Network, Kayln’s Kitchen, Skinny Taste. If you use Evernote to organize your list, it gives you one other advantage – you can download their add-on and clip recipes from the internet directly to Evernote. Each “note” (i.e. recipe) in Evernote can then be shared with whoever you cook with (i.e. whoever gets home first can start dinner!). It also lets you search all your notes so you can easily find your recipes in the future.

 

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Make a shopping list

I use Grocery IQ for my shopping list. This app lets you organize your grocery list by the aisles in your favorite stores to make shopping faster. It also allows you to share the list with your significant other which means that whoever is able to get to the store first has the updated shopping list!   I don’t really use the “coupon” feature or the barcode scanner, but if you choose to use these functions, please use the FoodEducate app with it to make sure your choices are healthy!

There are other apps for shopping which come recommended by others which, to be fair, I thought I should share: Any List, Pantry Manager, Paprika

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Shop once and (when you can) prep ahead

Planning lets you spend less time in the grocery store and absolutely means less food wasted. When you get home from the store think about the meals you are going to cook later in the week. If your carrot soup on Tuesday calls for sliced carrots, diced fennel and chopped onions, chop them when you get back from the store on Sunday and put your “mise en place” in baggies or containers in the refrigerator. Cooking is not that time consuming…. but prepping is!

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One other good trick is to make “mirepoix” on the weekend for the week. Diced onions, carrots, celery, bell peppers, etc can be prepped and put in a bag. It can be an instant stir-fry on nights when you need something fast.  You can also put a handful in soups, omelettes, or wraps to get extra vegetables in your day. Mix it with leftover rice or other grains to make an instant salad (you can add tuna, if you want, too).

 

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Use your day(s) off to cook things that might take a bit more time and freeze some for other days.

You need good “comfort food” when you are working hard, but it can be both comforting and healthy. For example, this recipe for spaghetti squash lasagna. The preparation for this recipe isn’t that hard (you can steam the spaghetti squash in the microwave instead of roasting it in the oven, for example) but it’s a little too long for nights when you get home late and are really tired.

Learning to use a pressure cooker (my favorite) or a slow cooker like a crock pot is a great way to cook up a batch of something when you are home and doing other things without spending a large amount of time in the kitchen

No matter what you make or how you make it, make enough to freeze individual portions and then store them so they will stay fresh. Don’t forget to mark the containers with a Sharpie and eat them within 3-4 months!

 

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Keep a few “instant” healthy meals in your pantry

Despite my best efforts to plan, there are weeks when I’ve miscalculated amounts, don’t have enough time or just don’t want to eat what I had planned. When that happens, it’s great to have a go-to “instant” meal, which usually comes out of the freezer and pantry. Here are some to get your list started!

Moroccan Lentil Stew – (particulary good with harissa and served over couscous)

Quick meals from frozen ravioli

Shrimp fried rice

 

food be your medicine

Yes, I’m a Surgeon and Yes, I teach Mindfulness

At the most recent ACS Clinical Congress, I was really struck by a presentation on mindfulness given by Sharmila Dissanaike and asked her if she would be willing to write about the topic for wellnessrounds.  To my delight she agreed!

 

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The recent #Ilooklikeasurgeon phenomenon reminded me that times do indeed change – albeit slowly. The peak of this phenomenon happened to coincide with my talk at the American College of Surgeons on “Mindfulness for Stress Reduction and Burnout Prevention”. If you had told me 10 years ago that I would one day deliver this brief lesson in stepping off the treadmill for a few moments, I would have said you were crazy. Surgery was only for the tough, and the tough don’t need breaks (or so we thought). As a woman surgeon, it was even more important to me that no chinks show in the armor, and being a trauma surgeon proved an easy way to solidify my “street cred” despite being a 5”2’ little brown woman with long hair.

So it has taken a while for me to feel confident enough to broach such a “soft” topic in a public surgical forum. Obviously age and (a little) wisdom has probably helped, but there is also a tangible change in the prevailing culture of surgery as exemplified by the #Ilooklikeasurgeon movement and other similar initiatives; where calling for help is no longer an (automatic) sign of weakness, and the surgical community has accepted that the good old days (or bad old days, depending on your perspective) are well and truly over. The next generation of surgeons is currently being greeted with much hand wringing and wailing and gnashing of teeth, for how could a group of kids raised in this limited workhour era possibly achieve the heights of excellence that the “old school” surgical residents achieved? Since the switch to 80-hour workweek happened exactly midway through my residency, I have the privilege of a foot in both worlds, and while I agree that our training paradigms do have to change, I am not yet ready to concede that the golden age of surgery is well and truly behind us. Partly, this is because of the audience that gathered for the session at ACS. What stunned me even more than the opportunity to speak on mindfulness was the full house that gathered for this session, and the enthusiasm and interest generated by a wonderful audience of men and women of all ages, and in nearly equal proportions – it embarrasses me to admit that I had expected to be speaking to a handful of younger female surgeons. Instead, I met the 65 year old broad-based general surgeon who came because he recently lost a younger orthopedic surgeon colleague to suicide – by stabbing himself through both femoral arteries, with surgical precision of course. I met several Governors of the College, who were in the classic “grey haired” demographic, and yet optimistic and enthusiastic about the future of surgery, and the improvements to be had by focusing more on our wellness – that “healing the healer” would have tangible results not just for our own wellbeing but also that of our families and our patients, and was thus an obligation, not an option. I met young surgeons a few years out of residency/fellowship who had already recognized the need for maintaining their own mental health in order to remain functional for as long as possible in order to maximize the productivity to be gained from their long training – working less was certainly not on their priority list. There was clear recognition of the systemic problems that drive a lot of surgeon frustration with ensuing burnout – bureaucracy, being treated as interchangeable expendable cogs in a machine, electronic medical records and endless paperwork topping the list – and yet there was also an acknowledgement that adjusting internal cognitive factors was at least as important for wellbeing as it was to try and change some of the external factors.

The methods I teach are focused on building resilience and capacity – characteristics that are both innate and learned, which can be developed and expanded through meditation and other techniques. One of my favorite analogies is that a spoon of salt in a cup of coffee renders it immediately unpalatable; the same spoon in a river or swimming pool would not be noticed. The spoon of salt represents the unavoidable daily irritants in our lives – the cases that run late, the scrub tech who doesn’t know what instruments you use, the colleague who lets you down in a key meeting. The cup of coffee of course is us – or at least, where most of us start. Instead of spending our lives either trying to avoid all these frustrations (which is futile) or becoming upset when they happen, mindfulness can increase our capacity to be with them fully, accept them for what they are and yet respond thoughtfully and effectively instead of blindly and automatically reacting with anger or frustration (which usually only causes us more trouble in the long run). Over time, we develop an increased capacity to handle irritation without it placing us in a perpetual bad mood, and increased resilience to bounce back from the inevitable traumas of life, both personal and professional.

So why teach mindfulness to surgeons, when there are plenty of other things I could be doing that would probably be more directly beneficial to my career? Because I do believe that the biggest waste of potential is to take a motivated young person, put them through the grueling training to be a surgeon, set them out on a career that is of such benefit to society, and then allow them to flounder and become discouraged 5 – 10 years later, quickly discarding those hard-earned skills as they turn into full time administrators, wound care docs or some other alternate career path. Not that there isn’t value to these professions of course, and some people do realize at a late stage that they are better suited to another path – in which case all of these are excellent choices. But too often it is one bad outcome that leads to a malpractice suit, or some other event that proves just too difficult to handle, that completely derails an otherwise excellent surgeon and this lack of coping – the lack of capacity, and resilience – leads to a complete abandonment of what should be an intrinsically rewarding career.

If mindfulness, meditation and other strategies can help even one surgeon regain a wider perspective and avoid this outcome, then it will have been a worthwhile endeavor.

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Dr. Dissanaike is a general surgeon with primary focus in trauma, burns and critical care, and a Professor at the Texas Tech University Health Sciences Center in Lubbock, TX. She serves as Medical Director of the Level 1 Trauma Center and Co-Director of the regional Burn Center. She has an interest in ethics and humanism, and is on the ethics committees of both the American College of Surgeons (ACS) as well as the American Burn Association.