No Time to Teach? Try This.

I’ve started a new practice as a medical educator that has been working so well that I thought I should share it. 

Once (or twice) a day in every teaching hospital every service makes rounds and, while managing and treating their patients, the attending (and/or senior residents) teach. 

Inevitably, there are unanswered questions that come up as we discuss patients. Many of them are questions I don’t know the answer to, or are related to a hot topic that might have new information just published. Here are some examples of questions that have come up on rounds on our pediatric surgery service:

  1. Are there new recommendations about how to manage gallstone pancreatitis and/or choledocholithiasis in kids? 
  2. What is the caloric content of the different formulas we prescribe?
  3. What is the best way to calculate calorie needs for a burn patient?
  4. How and why do you swaddle a baby?
  5. How do you manage supplemental oxygen after you extubate a patient with severe facial burns? 
  6. Where does “second line” come from?

Typically in the past, each student and intern would be assigned one or two of these questions to answer. They would be expected to report back to the team the next day – which might or might not happen depending on how busy the day was (and if the attending remembered to ask them). But to be honest, this way of teaching has become harder with time. There is a post-call resident who is not there the next day, the students often have didactic sessions that are required so they aren’t there, and the day can get so busy that there isn’t (perceived) time to teach on rounds.

But it’s our responsibility to teach (the word doctor means teacher!). Teaching is also a powerful antidote for burnout because its so important and so meaningful. It was clear – I had to come up with a way to make this work in spite of the limitations created by our schedules and clinical responsibilities. So here is what I do now in addition to teaching on rounds:

  1. During rounds we come up with one question per person (everyone, not just the students and interns). 
  2. Each person is responsible to answer their question via a group email that, as the attending, I start on the first day I’m rounding. 
  3. The answers are short and helpful – as though each person is taking notes for themselves. No PowerPoint presentations, no extensive diatribes. 
  4. The email answer is due before the next morning… but no one is allowed to stay up late to do this. 

Here’s what was sent on our group email to answer the examples I listed above.  (Disclaimer – These are unedited. Don’t use these for patient care unless you look things up yourself!): 

What is the “board answer” for treatment of gallstone pancreatitis? 

  • Usually mild as the stones pass spontaneously in the majority of patients but can be severe (even life-threatening) although this is rare. This is due both to fluid loss (equivalent of a severe burn) and to SIRS 
  • initial Tx: Fluid resuscitation, pain control, nutritional support (oral when patients are subjectively hungry – low fat diet) 
  • Surgery during the same hospitalization (Munoz, 2022) (Berger, 2020) (Noel, 2018) 
  • ERCP only if there is cholangitis or persistent cholestasis (Schepers, 2020) 

What is the “board answer” for treatment of choledocholithiasis. 

  • First step: Is it asymptomatic or symptomatic (i.e. pancreatitis, cholecystitis, cholangitis)? 
  • Emergency ERCP (<24hrs) for cholangitis, cholecystitis and/or pancreatitis with obstruction  
  • Stones must be cleared. There is no benefit to waiting and there is a downside to waiting since there is always a risk of cholangitis or pancreatitis with a stone in place.  
  • Most surgeons use pre-operative ERCP for known choledocholithiais followed by cholecystectomy, but ERCP at the time of cholecystectomy in adults (Rucci, 2018) (Cianci, 2021) and kids (Fishman, 2020) has been shown to be safe – and perhaps better.  

Calorie content of available Tube Feed/Supplements:

Two Cal HN – 2 Calories/mL – high protein

Glycerna 1.2 – 1.2 Calories/mL – lower glycemic index

Nepro Carb Steady – 1.8 Calories/mL – high fiber, gluten free, for lactose intolerant

Impact Peptide 1.5 – 1.5 Calories/mL – supposedly decreases risk of enteral infection in surgical/trauma patient with peptide formulation

Vital 1.2 – 1.2 Calories/mL with 1.2g of NutraFlora per 8oz for gut health

Pediasure Peptide 1.5 – 1.5 Calories/mL – designed for those with malabsorption

Ensure Plus – 1.5 Calories/mL with 16g protein

Osmolite 1.5 – 1.5 Calories/mL – fatty acids for different digestive profile

Jevity 1.2 – 1.2 Calories/mL with 4g fiber/8oz and 1.9 NutraFlora for gut health

Kate Farms 1.5 Peptide – 1.5 Calories/mL – supposedly marketing for smaller tubes without needing to be watered down

Nutritional needs for burn patients

Calorie calculator is complex: https://burnstrauma.biomedcentral.com/articles/10.1186/s41038-017-0076-x/tables/1

2.5-4.0 g/kg/day protein for burned children vs 1.5-2.0 g/kg/day for adults

Fat should be less than 15% of total calories

Carbs 7g/kg/day for burned children

Where did swaddling begin and why do we do it? How do you swaddle a baby?

Etymology/History

  • Swath (a strip in a field or a strip of cloth) 
  • 1325 first recorded use in English – Cursor Mundi (Gött.) l. 1343   A new-born child..Bunden wid a suadiling band (OED)
  • Almost universal in the 18th century, with or without a cradleboard

Benefits of Swaddling (van Sleuwen, 2007)

  • Infants arouse less and sleep more 
  • Soothes pain in infants 
  • Prevents hypothermia
  • Decreases excessive crying due to stimulation

Adverse effects of swaddling  (van Sleuwen, 2007)

  • Hyperthermia if not monitored
  • Increased risk of hip dysplasia
  • Increased risk of SIDS if prone
  • Promotes skin infections in hot, humid climates

Video showing three different methods of swaddling

Facial burns and airway management: 

*The mortality associated with orofacial burns or smoke inhalation is related to the degree of lung damage, patient’s age, and the extent of the burn; it is not related to the method of upper airway control.  Arch Surg. 1976

*In Facial burns, edema of the head and neck, supraglottic, and glottic areas is the most common cause of airway obstruction

Modified Tube for Endotracheal Airway Management of Children with Facial Burns Antonio G. Galvis, MD,

The team from this article designed a particular ETT setup

Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001). 

Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Critical Care Medicine. 1991 Mar;19(3):352-355. DOI: 10.1097/00003246-199103000-00012. PMID: 1999096.

What a second line means!

The “second line” refers to the spectators who join or follow the main line (usually the brass band) and contribute to the walking parade.  This is what separates a second line from any other New Orleans parade: groups are not only welcome but encouraged to follow along, allowing the second line to grow as it marches.  The term “second line” doesn’t only refer to the parade itself, it also speaks to the type of dancing you will find during those parades.  “Second lining” is a highly recognizable strutting, chicken-like dance move that many people use to keep pace with the band.  So “second line” is a term with many meanings; it applies to a type of parade, a part of the parade, and a dance move used within that parade.

@Teachers_Matter

Things I Wish I’d Known From the Beginning: OR Lights

One of my residents this morning thanked me for teaching her how to adjust the lights in the OR before a case. In fact, she said that since she had started this new practice that she hasn’t had to re-position the lights once while operating. There are so many minor details about the art of medicine that aren’t in books, so many things that make our lives easier…and that we wish someone had taught us earlier!

Operating Room Lights 101

Both lights should be positioned in the mid-line of the operative field – which means usually the mid-line of the table.

One of them should point straight down into the operative field. The second light should be either at the head or foot of the bed pointing into the field at an angle. If there are more than two, use them however it seems best.

Most importantly – You should position the lights BEFORE the procedure. Adjusting them after you start is always more difficult.

Operating Room Lights… Down the Historical Rabbit Hole

4500 BCE – Oil lamps

3000 BCE – Candles

1802 – Incandescent light invented by Humphrey Davy.

1850s – Operating rooms were built in the southeast corner on the top floor of hospitals to take advantage of natural sunlight. There were also four mirrors in the corners of the operating room to reflect sunlight toward the operating room table. (Wikipedia, Surgical Lighting).

1880s – Incandescent bulbs commercially available.

1920 –  The scialytic (which means “dispersing or dispelling shadows”) light invented by Professor Verain in 1920 was the first design to direct light around the head of the surgeon. This allowed operating rooms to be moved from the top floor of hospitals. (Ersek, 1972)

1930s – Fluorescent lights commercially available

1962 – First LED light developed

“The light must be sufficient in quantity, must be directed into the proper places, and must be of such a quality that the pathological conditions are recognizable. Also the light cannot produce glare, which will serve to blind the surgeon, just as the high headlights of an oncoming automobile may incapacitate an automobile operator; and it is just as dangerous.” (Beck, 1971)

There are four factors to consider in optimizing illumination (reference)

Luminance = reflected light. Too much = glare = eye strain.

Volume. This refers to the need to have light in more than one plane, which is important because we operate in three dimensions (which is why there are always two lights). This is also why surgeons wear headlights or use lighted retractors.

Shadow management. This is why the position of the lights is important!

Temperature. Was much more of an issue before LED lights.

Setting the lights to set your intention

Positioning the lights before an operation will help you see more clearly. This simple act can also become a ritual and a reminder of why you are there… to heal.

When a Thought Won’t Let You Go

We’ve all been there (yes, all of us). Something happens and we can’t stop thinking about it. It can be a complication, a misdiagnosis, something that happened in a toxic work environment, a failed exam, a harsh word. Not being able to let go of these thoughts means you are a normal person who cares… but it is not comfortable.

It will stop. At the time you are caught in the spiral of rumination, it seems unending. But it can’t and won’t last forever.

You are not your thoughts. There are your thoughts (and this annoying thought in particular)  and then there is “you”. Hold that thought (then see below).

Don’t make it worse by yelling. It’s human nature to try to push an uncomfortable thought or image out of your mind. But it doesn’t work. Yelling at yourself (in your mind) because you are not able to move past the thought/event makes it even worse.  

Get curious. Berating yourself makes it worse, but there is a way to disarm the thought and even make it go away:  

When the thought arises, just notice it. 

Wait….if “you” are noticing it, then the thought isn’t  “you”.

Exactly. 

Every single time the thought arises, say to yourself “I’m thinking about it again.”  But – and this is the most important thing – when you notice that the painful thought is back, you have to notice it without judgment.  Not… “I can’t believe I can’t let go of this thought.”…or “Something must be wrong with me.”… Just “There it is again.” 

Image from multiple internet sties

Mindfulness. The practice of noticing without judgment is called mindfulness. There are good data that an informal practice of mindfulness helps when we find ourselves with a thought that won’t let go. A daily practice helps even more. Set aside just 10 minutes and sit still. Just notice everything that comes up, acknowledge it, and don’t judge. Ditto for the next thought, and the next, and the next…

Here are some links if you’d like to learn more about mindfulness:

If you only read one thing about mindfulness, make it this book: The Miracle of Mindfulness: An Introduction to the Practice of Meditation by Thich Nhat Hanh

Headspace is a fantastic app to help you learn mindfulness

Mindfulness for Beginners from Psychology Today

National Suicide Prevention Lifeline 800-273-8255. You are precious. You matter. Call if you need someone to talk to.

Should I Go or Should I Stay?

I am sick and tired of COVID!

We are all sick and tired of COVID!

And we are all sick and tired of not seeing our friends….

So how do we decide if we should go to that big dinner or an out-of-town meeting in this complicated world of COVID-19? This is a classic ethical dilemma…and there is a tool kit* you can use to come up with an answer. 

Step 1: Assess the information. What do you know and what do you need to know?

The first question to ask is “Who are the parties involved?” If you are deciding whether to go to an event, It clearly affects you and the other people who might be going to the event, but who else will be affected by the final decision? 

The next two questions in this step are straightforward: What do you know? What else do you need to know?

Step 2: Think out of the box.

Every ethical dilemma has a “yes-no” answer, in this case to go or not to go to the event. But what other actions might be possible? Limit the number of people? Require testing and/or masks? Is there an option to participate virtually? This step should be a serious brainstorming exercise to explore ANY possible option (if you do it right, there will be some things on the list that sound almost crazy). 

Step 3: Consider the Appeals

This is a fancy way of saying how do the possible choices fit with your values and what we, as a society, think are virtues?  

Considering the appeals starts with a simple question – “Is there a rule?”  For example, does your employer have a rule limiting travel during the pandemic?  Are you traveling to a state that has a law prohibiting mask mandates? 

The second question in this process is “What could go wrong?” What are the possible consequences of each option? If one option is to pay a little extra to be able to get a refund on your plane ticket, it’s probably not going to be important in making your final decision. But if it turns out that your decision might lead you to inadvertently infect your 70-year-old mentor with COVID, that’s more serious. Once you get a list of all the possible consequences try to put them in order of significance by asking if they are serious, irreversible, and/or likely. 

The third question is “Which choices have more virtue?”. Which ones are more likely to reflect what we, as a society, think are behaviors and motivations that good human beings demonstrate? Most of us will agree that compassion, courage, self-sacrifice, legitimately protecting ourselves, integrity, and honesty are virtues, but there may be others that are important to you. Here is a link to see a long list of virtues to consider. 

Step 4: Decide

It’s time to decide. Look at all the objective data (step 1), the list of possible actions (step 2), and which of the actions has the most virtue (step 3). Some of them will have more weight for you than others. That’s not only ok, it’s important. We may come to different conclusions, but using this process, we will both know why.

Step 5: What could have been done to avoid this in the first place? 

This step won’t change your current dilemma, but it will help you and others with future decisions. 

Let’s assume you’ve been invited to speak to a group next month. It’s an honor, and it’s a talk you love to give! But we are in the middle of a pandemic… should you say yes? 

Step 1: Assess the information

Who are the parties involved?

You, the organizers, the people who will (or won’t) hear your talk, the people in your life you might infect if you get COVID, your work partners, the organization you work for.

What do you know? 

It’s an honor to be asked, so this is good for your career. You love this topic and you really want to give this talk. The number of people who will be at the meeting (based on past meetings) will be between 700 and 800. Given the demographics, it’s likely that >95% of the people at the meeting will be vaccinated. You are vaccinated and boosted. The state they are holding the meeting in has a law prohibiting mask mandates and the organization has not put out any directives about masking or testing. The state they are holding the meeting in has an unvaccinated rate of … % and a COVID prevalence of … %. (Here’s where to look up these data.) There are people in your professional and personal life who are at high risk if you were to inadvertently bring COVID back to them. 

What do you need to know?

Have the organizers addressed the issue of the mask mandate?  Are the organizers going to require masks? Testing?  Does your employer have rules or recommendations about travelling?

Step 2: Options

The obvious

  • Go to the meeting
  • Don’t go to the meeting

The not so obvious

  • Go to the meeting
    • But just for the day you are presenting and don’t attend any other sessions
    • Go but avoid social gatherings and wear a N95 all the time
  • Don’t go to the meeting
    • Ask if they would consider a hybrid meeting so you can present virtually 
    • Record your presentation so they can show it during your session

Step 3: Appeals

  • Rules/laws: The law in the state to not mandate masks should be addressed by the organizers of the meeting, but you can choose to wear a mask regardless. There aren’t any other obvious rules or laws that apply (unless your employer has restrictions on travel).
  • Consequences. If you go to the meeting you might contract COVID (possibly serious, only remotely irreversible, possible but not likely). You could bring it home to others (possibly serious, only remotely irreversible, unlikely). If you are sick there will be a burden placed on your work partners (could be serious, not that likely)  If you don’t go to the meeting you might lose your status in the organization (possibly serious, only remotely irreversible)
  • What is the most virtuous thing to do? It may make the most sense to ask if the organizers will allow a hybrid approach so you can present virtually – or if they would let you record your presentation. But if those aren’t possible, you’ll need to decide if you are going or not. If you go to the meeting you are showing integrity (You said you would do it, so you are following through) and self-sacrifice (The organizers thought you had something important to say, so you are willing to take the risk). If you don’t go to the meeting you are showing legitimate self-interest (protecting yourself), compassion (for the family and friends you might inadvertently infect).You are also showing care and respect for your work partners, who would be burdened if you were to become ill. 

So… do you go or do you stay? 

*To give credit where credit is due: The process described above is a slightly modified version of the “Ethics Workup” originally developed by the faculty of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. 

MD, MDiv

I published my first article addressing physician wellness in 2009. Physician wellbeing wasn’t ever part of my academic plan, but over time it became part of my mission. As a Program Director, Dean of Student Affairs, and mentor I watched, and wasn’t always able to help, trainees and colleagues as they struggled. This struggle, which we have (I believe inappropriately) called “burnout” led to weariness, sadness, and distress for almost everyone in my sphere of influence, no matter where they were in their professional journey. 

For some it was career limiting. 

For some it was life limiting

For some it was fatal. 

As physician suicide and burnout in medicine became a reality that couldn’t be ignored, I became part of the movement of healers who began to work with policy makers and hospital administrators to try to make a difference. We worked on ways to convince those in power that this was not just about doing the right thing, but that it helped institutions with their metrics of success since it was clear that physicians in distress affected the bottom line. Despite these efforts, there was rarely any substantial change. In fact, most of us agreed that both objectively and subjectively things were getting worse. I began to realize we weren’t speaking the same language. They were measuring attendance at mandatory wellness training sessions and celebrating “success” because >90% of docs attended. But they weren’t measuring the right thing. They weren’t paying attention to metrics of healer distress, how many of their physicians were quitting their career in medicine, the number of divorces, the rate of substance abuse, or, most tragically, the increasing number of healers who were dying by suicide.

Let me pause here for a minute to state something obvious. I know that policy makers and hospital administrators don’t go to work to make life difficult for the healers in their systems. In fact, I suspect that they are experiencing much of the same distress that we are experiencing because, at its core, the issue here is what we value and how we talk about those values. 

I began to wonder if we needed an entirely new approach. So I went back to graduate school. Most of my friends thought it was crazy that at this stage of a classic academic career, I would go back to school, but I did. I enrolled in the Master of Divinity program at Iliff School of Theology to learn new ways to think about values… and different ways to heal.

I will continue to talk about how to eat well at work because our physical well-being is important. I will also keep writing here (and elsewhere) about staying connected with and for others, because our mental health is also important. But in the weeks and months to come I hope to write more about values and how we might work together, healers and administrators, to heal our patients – and each other. 

Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P. Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. Am J Med. 2019 May;132(5):556-563. PMID: 30553832.


Gifts for Medical Students, Residents, Physicians, and Anyone Else with a Stressful Job

The Gift of More Free Time

The everyday needs of a household can become oppressive if you are working 80 hours a week. And, because bathrooms need to be cleaned, and floors need to be vacuumed, this is time that takes away from downtime needed to recover from hard work.

Here’s a list of things that just about every healer or healer in training would appreciate to help free up time:

  • A cleaning service. Hire someone to do a “deep clean” of their home once a month. Look on the internet for bonded cleaning services or call people who might know the best companies.
  • Car washes. Who doesn’t love a clean car…. and who has the time to wash and vacuum their car?
  • Roomba vacuum cleaner. One task taken care of!
  • Someone else to cook meals (see below!)

The Gift of Nourishing Food

  • Instant Pot. The number one time saving kitchen appliance for busy people is the Instant Pot. My Instant Pot has fundamentally changed the way I cook – and has made it easier to eat well.
  • Air Fryer. I’m a new convert to air fryers. 15 minutes to get wonderful roasted or air fried veggies is amazing! There is now an Instant Pot with an air fryer built in – a great option for a gift!
  • Gift certificates for food. Do a little sleuthing and find a healthy grocery store near where they live. Other ideas might be a smoothie or juice shop, their favorite restaurant(s), or coffee shops
  • Prepared meals. Most cities have small, local companies that deliver prepared meals to your door. They usually offer gift certificates which is probably the best plan to give flexibility between a subscription or a la carte ordering.
  • Home cooked meals. If you live near, think about cooking a batch of favorite food(s) and putting them in single serving containers to freeze. You might also want to create a certificate for your personal “cookie/meal/soup of the month club” with a promise to deliver food once a month.
  • A Good Cookbook. Mark Bittman’s cookbooks are all wonderful, but How to Cook Everything Fast is a particularly good choice for busy people.
  • Vitamix. It may seem expensive for a “blender”… but this is much more than a blender. These are the blenders you see in professional smoothie stores. Smoothies become a lifesaver for busy healers. (The Vitamix also makes great soups, sauces, etc…..)

The Gift of Good Beverages

  • Insulated Coffee Mug. Rounds in the morning often starts with “running the list” around a computer, often at “dark thirty” when the rest of the world is just thinking about getting up. Having good coffee or tea from home or a local shop that stays warm for several hours is such a pleasure. The mug of choice for just about everyone I know is a 10 or 16 oz Yeti tumbler.
  • Water Bottle. No one drinks enough water at work in the hospital (and we all agree on this). Again, having a great water bottle that you can fill in the morning with ice water (and a slice of lemon if you like) makes the day better.
  • Nespresso (or other) coffee maker. If you are a coffee drinker, a good coffee maker is key. Nespresso is my personal favorite, but be creative and look at all the options!
  • Good coffee (or tea). There are local roasters in most cities, so rather than support the big chains, look for them and consider a gift of coffee.

The Gift of Music

For those who find solace and joy in good music (and isn’t that just about all of us?):

  • A good Bluetooth speaker for their home or study space. I love the Klipsch The One II speaker I have at home, but I’m sure there are other equivalent speakers, including some that aren’t as expensive.
  • Air pods or noise cancelling headphones
  • A subscription to one of the many streaming music services like Spotify or Apple Music.
  • Tickets to the symphony, ballet, jazz performances, or opera in the city where they live.

The Gift of Good Sleep

  • Good mattress, pillows, sheets. How we sleep determines how well we function the next day, particularly in high stress jobs. Is it time for a new mattress? Is there a better mattress that might help? High quality sheets are usually a welcome gift, too.
  • Light blocking curtains or shades. Post-call sleep is during the day and sunlight can interfere with sleep. Special curtains or shades to block the sun really help.
  • A Weighted Blanket.
  • Nothing Much Happens. This is a free podcast with the subtitle of “Bedtime stories for adults”. Since it’s a present, think about supporting this wonderful series with the very cheap subscription (which means you get the stories without ads.)

The Gift of Healthy (and not aching) Feet

Working in the hospital means a lot of time on your feet. John Wooden, probably the most famous basketball coach of all time, spent the first week of training every year teaching his players how to put on their socks…. because he recognized that if you didn’t pay attention to your feet, it would affect your game. The same is true in medicine.

  • Comfortable shoes for the hospital which can be thrown  into a washing machine. High on the list are Atoms, AllBirds, and Merrells. I have shoes from all three companies and so, for some one like me (a surgeon) who walks and stands a lot, I can recommend these specific shoes! Atoms Sneaker, Allbirds Tree Runners, Merrell Encore Breeze, Merrell Antora 2 Rainbow,
  • Good socks. Don’t go for cute, go for high quality, well padded, and functional.
  • Compression socks. There is some debate about whether compression socks can really prevent varicose veins, but there is no debate that your feet feel better at the end of a long day when you wear them!
  • Pedicures. Lots of women (and some men!)  have learned the joy of a professional pedicure for tired feet. Don’t underestimate the power of a gift certificate for  pedicures. But, as an alternative, put together a kit for home pedicures.

The Gift of Fitness

This might not apply to everyone, but most people who work hard know that they feel better if they exercise a little every day. But – a word of caution – tread lightly with fitness gifts since they can be misinterpreted as conveying a “need” to exercise.

  • A bicycle. For many people a good bicycle can make it easy to add some exercise by commuting to work by biking instead of driving. Regardless, it’s a great way to get some exercise outside. If they have a bike they use to commute, you might think of some ways to make it easier such as
  • A gym membership. You may have to do a little detective work to find the right gym that is close to where they live, but it’s worth it.
  • New shoes. Runners are supposed to get new shoes every year or so. Give them a gift certificate from a running store near them, if there is one. Or, be creative and put cash in a tiny toy shoes and wrap them in a shoe box.
  • Fitness equipment for home. Resistance training is important for all of us, regardless of gender or age. Although a bench and weights are part of the classic home gym, they take up a lot of room (and weigh a lot!). I’m a big fan of the TRX system, which makes a great present. Since it has become almost a cult among physicians during the pandemic, I have to at least mention Peleton as another potential fitness gift for healers and healers in training.

The Gift of Calm

Massage and/or Spa Services. This, too, may take a little effort to find the right place, but this is a wonderful gift for stressed people.

Headspace. This might seem a little unusual as a gift idea, but I can’t recommend it enough. Meditation is discussed in most medical schools and hospitals as a tool to gain insight and recover from the depletion that is part of the work we do. The best way I’ve found to learn this practice, and then stick with it is Headspace, which is a great app. The first 10 lessons are free, but for a gift, go ahead and get the annual subscription.

The Gift of Time and Stories

Human beings heal their hearts and souls by telling stories. Although there are many stories your loved one can’t tell you (at least not the specifics) you can totally ask how what they are seeing and doing is making them feel. Set aside some time for a coffee or another beverage and ask – with intention – “How are you doing?” And then just listen. Don’t try to “fix” anything … just listen.

Along the same lines, think about a letter… yes, a handwritten letter or note. Maybe a long one for a specific holiday or birthday, maybe a series of shorter ones through the year. Imagine how you would feel after a particularly hard week if you had a letter to reread that talked about how proud someone was of you, filled with funny stories and words of support.

How To Publish Papers as a Medical Student or Resident

First and second year medical students often are anxious about the “need” to publish but have trouble finding details about the process and goals of writing. Yes, it’s true. If you are going to be applying in a competitive specialty, you need to have at least one (but maybe a few more) publications. BUT (and this is really important, so please pay attention) there are two important things for you to know:

It’s called academic medicine because we are part of the academy! That means that we are trying to teach and change outcomes for the future. Don’t look on these papers as a “check box”. Find a meaningful question and learn from a mentor how to answer it. You will make a difference!

Secondly, you do NOT have to publish in the field you will ultimately choose. Publications are really a surrogate for being able to think, work in a team, and write. It’s showing that you can take a complex task and actually complete it. No one expects a first or second year student to know they want to be an expert in the pathology of Hodgkin’s disease! The key is to find a mentor who will teach you the process and show you how meaningful and fun it is to study something in depth and then share what you learned with others.

So how do you do this? It starts with a blank form:

So let’s break down the five steps from starting to publishing a clinical research project…. The times in parentheses are my estimates for how long this takes for a student who is on clinical rotations. If you are doing this full time as an month long research elective, it will take less time for each step. (But – note to self – you need to get the IRB request in 2 months before your research elective starts!)

Store your PDFs in Zotero – you can attach it as a file if it doesn’t automatically download. Don’t forget to add the Zotero plugin to Word if it doesn’t automatically install.

This last step is the key step (my opinion, others may have other strategies). My goal is to read each article ONCE.  Therefore, I put EVERYTHING I think might be of interest from each article as I create my outline. It’s a lot easier to edit things out than add things in…

I start with an outline in Word that has headings something like this….

  • Introduction
  • Epidemiology
  • Pathophysiology
  • Natural history of the disease
  • Presentation
  • Treatment
  • Outcomes
  • Complications

So, I might read this paragraph in an article written by Smith et al in 2015 (I’m making this up – don’t quote anything written below!)

Pyloric stenosis was first described in 1886.  Prior to the introduction of surgical treatment, the death rate was 50%.  Surgery, which started in 1923 has now led to an almost 100% success rate with no mortality.  The typical patient is male, and 4-6 weeks of age.  They present with projectile, non-bilious vomiting and do not appear ill between episodes of vomiting.

So – using the outline in Word and Zotero I would do this…..

You then go on to subsequent articles and – even if they mention the same detail – you put it into the outline. For example, if you found 4 articles that said the typical age was 4-6 weeks, it would look like this: Typically 4-6 weeks (Smith, 2015) (Brown, 2011), (Jones, 2000) (Who, 1014)

Next, use your outline to start actually writing about the information you have gathered. As an example, switch to the “text” setting to change your note about age at presentation from “Typically 4-6 weeks (Smith, 2015) (Brown, 2011), (Jones, 2000) (Who, 1014)” to text that says “The average age at presentation is 4-6 weeks (Smith, 2015) (Brown, 2011), (Jones, 2000) (Who, 1014)”

How to save yourself hours by using Outline View properly

The Institutional Review Board is responsible for protecting patients participating in research.  Even if you are “only” reviewing charts, they must be protected with respect to confidentiality, etc.  This is not usually true for case reports, but since many journals require IRB approval, you may have to submit it anyway and have the IRB letter that says it’s exempt.

It takes approximately 6-8 weeks to get the IRB approval after it is submitted.  If they require modifications, it can take longer.  You can’t (and shouldn’t) look at charts until you get this approval.

You must have IRB approval before you can submit the list of patients from the hospital with the disease you are studying. If they are treated by doctors other than the faculty you are working with, the IRB may ask you to send a letter via the hospital medical staff office to the other doctors giving them the option to exclude their patients if they want to.  (They virtually never do, but this is a required step)

The “term paper” is just what is sounds like.  Depending on the topic, it will be ~6-15 pages long with ~20-60 references. Here is where the outline and Zotero are so important.

Change the “view” in your outline to “draft”. The outline levels will be in Blue and will now be section headings. Everything that you wrote as text will be just that – text. You can write in this view or go back and forth between the draft and the outline if you want to rearrange sections.

All of the links to the references you put into Zotero using “Add/Edit Citation” will be in your draft. At this point, you click on “Add/Edit Bibliography”. It will prompt you to choose which journal you want (Yes! It knows the format of all the major journals!) and then will automatically create the bibliography. If you add new references in at the top of the manuscript, or change the order of the sections, you click this again, and it recreates the bibliography in the correct order.

As you are creating the outline, you are also designing the “data sheet” to retrieve from the charts the details you need to prove your hypothesis.

Writing a term paper is a great way to become an expert in the topic you are researching, but it also helps you later. The hardest part of any final paper to write is the introduction and conclusion – which you mostly do by writing the term paper!

Once you’ve got to this stage, you want to skim through the articles again to see if there are any “big picture” points you might have missed and then write the summary – i.e. the abstract.

It is ALWAYS better to write the abstract after the manuscript if you can.  But – many times the deadline for the abstract will be used as the motivation/pressure to write the manuscript.  Each attending will do this a little differently. 

Use this section as a “journal” for your submission and for notes during meetings.

Good luck with your projects! I hope this helped!

We Are Neighbors

I look around the spaces I work, live, and worship in and I see so many people I love. I believe everyone is my neighbor, but I’m specifically talking about the people I know…the smiling clerk I always choose to check out my groceries, the guy who waves at me every morning when I drive into the garage, my family, the people who share my mission of healing children.

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Only ~50% of the country is vaccinated and in some areas it’s only about ~30%. I know this means that some, maybe many, of the people I know and love aren’t vaccinated and, to be honest, it’s breaking my heart.

Because here’s the deal…

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The Delta variant is dangerous. Every person who is infected with the Delta variant will infect 6-8 people on average (which is more infectious than Ebola or chicken pox)… Unless you are in a group of people like a break room, a church, a gym…. In which case the number will be much higher because of the closed space. Being vaccinated makes it MUCH less likely, but not impossible to infect people around you other because of “breakthrough infections.” These infections after vaccination are rare but expected – it doesn’t mean that the vaccine “didn’t work”.

Masks protect you (some) and everyone around you (a lot) which is why they are so important now – whether or not you are vaccinated.

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But back to my friends and neighbors who aren’t vaccinated. The Delta variant is so infectious and spreading so fast that if you aren’t vaccinated, it’s not about IF you get infected, it’s about WHEN.

That’s why when I think about my beloved friends and neighbors I grieve because…

You will almost surely be infected with the Delta variant if you aren’t vaccinated.

You will go on to infect others around you, including people you love.

You will be sick (and probably really sick)… hopefully at home, but maybe not.

You may end up on a ventilator.

You may die.

And if you don’t die, you may be debilitated.

And it breaks my heart. Because these deaths are preventable.  And even one of you dying or being debilitated is one too many.

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I beg you…Get vaccinated. Wear a mask. #LoveYourNeighbor

(p.s. We are all neighbors)

“Running the List”

Where did this term come from?

For those not in medicine:

  • A busy hospital service needs a way to keep up with the “to dos” of the day.
  • The junior residents and students responsible for these tasks need a way to know what they’ve done and what still needs to be done.
  • The senior residents and attendings need to keep track of the information and what is happening to guide and supervise the junior residents and students.

And all of this means keeping an accurate and up to date patient list. This can happen digitally in Epic, which is often what attendings use, but for most residents and students it means printing out the Epic list to keep in their pocket as they move through their day (and/or night).

p.s. If by chance you are still making your residents use Excel i.e. they have to physically create the patient list, shame on you! (Unless you don’t have Epic or another digital way to keep the list, in which case, I’m really sorry.)

And how do residents and students use the patient list?

  • Almost everyone draws little boxes for every detail they need to check off … and then puts a check in the box when it’s done.
  • Different colors for different tasks? Doodles? Notes during rounds or lectures? All of these and more, I’m sure.
  • Fine tipped pens are key (Every resident has a favorite type of pen which they hide from their attendings).

And then we run the list

“Running the list” means starting at the top of the list and discussing each patient sequentially, one at a time. We make sure to go over the plan for each patient, discuss what has changed, learn what has been “checked off”, and decide what needs to be added to the list.

This happens routinely at the beginning and end of the work day, and during handoffs. But, on a busy day, it may happen even more often.

So back to the original question

Although it sometimes actually feels like the intellectual equivalent of running, I suspect that the origin of “running the list” has to do with the idea of a “running list” i.e. a list that you add to as new things come up. But that’s just an educated guess, since I couldn’t find any actual data. If you have other thoughts, let me know!

Final thoughts

Running the list is an important part of caring for patients, but it can also be a practice.

What if, like a competitive runner, you took a moment before you “run” the list to center yourself, take a few deep breaths and get ready to run?

What if you tried to visualize each person on the list as you review the day’s tasks to remember that these aren’t just tasks… they are human beings in your care?

What if we consistently made it a goal to teach just a little bit (or a lot, if the time permits) every time we run the list? (Would this be “walking” the list? 🙂 )

And at the end of the day, when you put your patient list in the shredder (don’t forget this important step! #HIPPA), what if you did it intentionally – to mark the end of the work day and the transition to not being in the hospital?

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Shoes to Wear in the Hospital (And Other Tips for Your Feet)

Working as a surgeon for as long as I have, trust me, I have learned the agony and ecstasy of foot care. After a long case or after 24 hours on my feet it’s the agony. But I’ve learned how to make my feet happy… and I’ve learned that it’s not that hard.

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Shoes

The ideal hospital shoe has a wide toe box, is flat, laced (I’ll get to clogs in a minute), lightweight, slip-resistant, fluid resistant, and can be thrown into the washing machine. You can expect to spend around $100 for these shoes. Don’t get cheap shoes – spend the money!

Although many running shoes meet these criteria, my current favorite shoe is from Merrell, which has been a go to company for me for years. The other major contender right now for favorite hospital shoe among medical students and residents is All-Birds.

Even though I wear lace up Merrells most days at work, I love clogs when I operate. They let me back my feet out of them and lower my heels to stretch my calves.  I can kick them off and stand barefoot for a while if I need to change the pressure points on my feet. I had Dansko clogs for years, which are almost a tradition for surgeons, and then changed to Merrell clogs (which are pictured above)  Although they are great for standing, the problem with clogs is that your toes have to grip the shoe when you walk (or run to a code), which means they aren’t the best shoes for the rest of your day.

Here are some other options beside running shoes, Merrells, and All-Birds to consider. If you have tried these or have other shoes I should add to the list, please let me know!

Atoms – Great reviews and an amazing story about the owner of the company

Bala Shoes – designed by nurses with consideration for structural differences in women’s feet

Birkenstock shoes

Brooks Addiction Walker

Casca Shoes – This is an interesting company that offers custom fit and a variety of options

Clarks

Columbia Tamiami

New Balance Slip Resistant 626v2 work shoes

Timberland TrueCloud

TropicFeel

A note about high heels…

There is practically nothing worse for your feet than wearing high heels. (Sorry if you love them). If you wear them, please wear them only for special occasions and keep the heels as low as you can. If you are wearing heels in the hospital because it hurts to not wear heels, that’s a huge red flag and you need to really work on it.

Socks

When John Wooden, arguably the most famous coach in the NBA, starts the season by teaching his players how to put their socks on correctly, you can bet it’s important. Don’t skimp on socks. Buy good socks that fit well and take time to put them on correctly.  

Compression socks have the potential to change your life. Ok, maybe that’s an exaggeration, but this is one thing I wish I had started earlier in my career. It’s not clear that they do anything to prevent the occupational hazard of varicose veins, but boy do they make your legs feel better at the end of a long day.

Make sure you throw an extra pair of socks in your call bag. There is nothing that feels better than taking your shoes and socks off after 10-12 hours,  massaging and stretching your feet (if you have time) and putting on new socks before the second half of a 24 hour call. BTW, the same is true for shoes. Swapping out shoes (if you have two good pairs) is also really nice for your feet during a 24-hour call.

Foot stretching and massage – every day

A friend recently lent me this book which is written by Katy Bowman, with the help of 4 “goldeners” (all older than 70) about what they wish they’d known about caring for their physical wellbeing. Feet are literally the foundation of our musculoskeletal “chain” and unhealthy feet not only hurt, they can affect the function of your kness, hips, and back. Here is the routine recommended in the book to care for your feet. It only takes about 10 minutes and is something you will look forward to doing at the end of the day since it feels so good.

  1. Dorsal foot stretch. Put the top of your foot on the floor and stretch your toes and ankle. Hold it at least 30 seconds and repeat it at least three times. If you get bad cramps (which is normal if it’s tight) it just means you need to keep doing it. Let the cramp subside and start again.
  2. Sole of the foot stretch. Buy this foot massager (or one like it) right now! Stand on it to to stretch and massage every single square centimeter of the sole of your foot. You’re welcome.
  3. Toe circles. Grab each toe separately, pull on it a little and then move it in a circle (both ways) for several rotations.
  4. Toe stretches. Pull each toe away from each other (medial to lateral) then put your fingers between the toes and leave them there to continue the stretch
  5. Toe lifts. Lift your big toe first and work your way up to lifting the other toes as individually and as high as they let you.

As an alternative, if you want a guided yoga practice for your feet, check out this video from the amazing Adrienne Mishler.

Pedicures and Ingrown Toenails

Every time you take a shower, look at your feet with intention. If you have calluses use a pumice stone to take off the layers of dead skin. Don’t let your toenails get out past the end of your toes and never cut them in a curve like you do your fingernails. If you start to get an ingrown toenail, soak your feet twice a day, dry them well, and then wiggle dental floss under the corners of the nail. Leave the dental floss in place until the next time you soak and then put another piece under the corner of the nail. Continue doing this until the nail grows out enough to be cut straight across. Since toenails grow about one millimeter a month, plan on it taking at least a month.

By the way, if you’ve never had a professional pedicure, ask around to find a good place and try it. It’s not just for women, so if you are a man who has never tried this, step out of your comfort zone (no pun intended) and try it at least once!