It is a personal ritual that I read this poem every year on the first day of spring, so I thought I would share it today.
Happy First Day of Spring – and International Happiness Day!
It is a personal ritual that I read this poem every year on the first day of spring, so I thought I would share it today.
Happy First Day of Spring – and International Happiness Day!
If you don’t work in an operating room, you may not be aware of the controversy going on about OR caps. To get right to the point – the surgeons think they should be allowed to wear the cloth hats they have worn forever. The Association of Operating Room Nurses (AORN) developed guidelines which included covering the ears and all hair (which means a bouffant paper hat). These guidelines were then implemented by JACHO which means they became “law” in every hospital in the United States.
I’m a real believer in evidence based medicine (and policies) so I decided, like others, to look into what is really known about the issue. Because it is a conflict of interest, I need to disclose that I can’t stand the bouffant hats and I really, really miss my (clean and washed) cloth hats. (which BTW cover all my hair!)
What do the data say about the use of bouffant hats and infection rates?
Why don’t surgeons like bouffant hats?
It’s harder to keep them in place when wearing loupes or headlamps. If the goal is to keep the hair covered, this is a real problem. When moving headlamps, operating microscopes or loupes, the bouffant hat often moves substantially – or even comes off entirely.
They are hot. Many surgeons feel (me included) that the bouffant hats are uncomfortable and are hot. One can argue that anything that increases surgeon discomfort could affect concentration, which might be reflected in less focus on the operation.
Bouffant hats are expensive and bad for the environment. On Amazon, 100 bouffant hats cost $7.45. There were 48 million inpatient operations performed in 2009. When you add the 48 million outpatient procedures performed, that means there are roughly 100 million operations performed per year. (Mind you, these data are almost 10 years old, so it’s likely to be more now). If we assume an average of 4 cases/day by an average surgical team (nurses, CRNA, anesthesiologist, assistants/resident) and they all wear their hat for the day, the number of hats needed per year would be 100 million cases x 6 members of the team = 600 million hats/yr. 600 million hats divided by 100/box = 6 million boxes x $7.45 = $44,700, 000. Over 44 million dollars a year for the bouffant hats… all of which (600 million/year) end up in a land fill or are incinerated. p.s. Given that hats are often changed during the day, this number is probably on the low side.
It affects morale. In a survey of young (<45 years of age) surgeons, 71.2% stated that the new rules had affected surgeon morale.
They are inferior in blocking bacteria when compared to other caps. In a study of bouffant hats, disposable skull caps and cloth hats, the bouffant hat was the worst in preventing airborne bacterial contamination in the operating room. “I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.” Troy A. Markel, MD, FACS
I’m confident that in the very near future we will be back to wearing our clean, cloth hats. When you look at the data, and weigh the pros and cons, it seems pretty obvious what needs to be done….
I teach embryology to wonderful first year medical, nurse anesthetist and PA students. Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.
Let’s talk embryology.
I am very, very confident that the blastocyst doesn’t feel pain. I am equally confident that babies at the time of birth do feel pain. So, there must be a moment during development when nerves to sense the pain, nerves to transmit the pain, and a brain to perceive the pain come together to make it possible to perceive noxious stimuli. I’m not a developmental neurologist, so I can’t claim to be an expert, but based on published research, those three things are present somewhere around 22-24 weeks gestation. For those that are concerned about abortions that happen after 22-24 weeks, It’s important to realize that only 1.3% of abortions occur after 21 weeks gestation and 80% of these for serious birth defects.
Let’s talk suffering.
As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.
A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.
A young couple comes to their gynecologist for a routine screening ultrasound. Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.
Let’s talk ethics.
We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.
Let’s talk about listening.
When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.
As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient. Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.
This may be one of the easiest kitchen tricks I’ve learned in the last few years. I haven’t bought any stock since I figured this out. It saves money, but more importantly, this stock tastes MUCH better than anything you can buy.
Step 1: As you peel, chop, and otherwise use any vegetables for recipes or salads, save all the pieces you would normally throw away.
The vegetables that help the most with umami (and make your stock great) are the classic mirepox (carrots, celery and onion), garlic bits, and mushrooms. There are a few vegetables you should avoid using for stock. Some vegetables will make the stock bitter or impart a strong, very specific taste that may not work in some recipes (e.g eggplant, turnips, cilantro, ginger). If you happen to be someone who buys Parmesan cheese with a rind, those rinds are wonderful in stocks. If you use fresh herbs when you cook, make sure you throw the stems in the stock.
Step 2: Keep a big ziplock bag in the freezer and toss the washed bits you saved into the bag. When you drain beans, tomatoes or other vegetables from cans, put the juice in the bag, too.
Step 3: When the bag is full, put the frozen vegetable bits in a big pot with water to cover them, bring to a boil and then simmer for about an hour.
If you have an Instant Pot, you can make stock in less time. I don’t add salt while making the stock because it lets me season the dishes I make to taste.
Step 4: Freeze the stock you don’t use in a day or two.
I usually freeze my stock in 1-2 cup plastic containers. Alternatively, use freezer bags if you want to take up less space in your freezer (Push the air out of the bags and lay them flat on a cookie sheet to freeze). Another trick is to freeze the stock in ice cube trays or muffin tins and then put the frozen stock in freezer bags.
In addition to recipes, use this stock instead of water when you make rice or grains. Thaw your stock in the refrigerator (if you remember) or in the microwave (if you don’t).
We eat a mainly plant based diet, so I only make vegetable stock. If you eat meat, you can save the bits from the meat or fish you cook – or ask your butcher for stock worthy bones and add them to the vegetables to make great chicken, beef or seafood stock. If you want perfect chicken or beef stock, you may have a bit more work to do… 🙂
It is hard to eat well when you are a medstudent, resident or busy doc (also true for busy people not in medicine The key to eating well if you are busy is planning.. but it takes time. As I’ve written before, here are the basic steps that you need to follow to eat well if you are “too busy to cook”.
To follow these steps, I’ve used the internet to find recipes, Evernote to map out the week, and Grocery IQ for the shopping list. I’ve gotten pretty efficient, but it’s still takes a non-trivial amount of time… and who has that kind of time, right?
And then I read Jane Friedman’s post “My Must-Have Digital Media Tools: 2018 Edition” and I saw this…
Here’s the bottom line… this app is “expensive” ($25). But I promise, even if you are medical student without much money, it will be the best $25 you’ll spend this year.
Here’s why – this app takes the five steps listed above and puts them all into one place. It not only makes it easy to choose recipes, plan your week and shop, it almost makes it fun. Here’s how:
Use a calendar to organize which days you need to have dinner ready.
Start on the “meals” tab and put notes in for your week. If you share cooking with a significant other or roommates, you can share the account with them so everyone is (literally) on the same page.
Click on the browser tab to find new recipes. As you gather recipes in the app, it becomes your own personal “cookbook” which is searchable by category, name, or ingredients.
This was the first moment I knew I was really hooked. All you do is drag and drop the recipes you want into the appropriate day. Wow.
This is when I was completely sold. When you pull up the recipes you’ve chosen, there is a little “hat” icon at the top:
Because this app is on your computer and your phone, just take your phone with you to the grocery store. As you pick up the item, click the box next to it and move on to the next item. If you are sharing the app with your significant other or roommates, anyone can add to the grocery list or unclick things they have bought.
Here’s the official website for Paprika: https://www.paprikaapp.com/. Enjoy your healthy eating!!!! Try this plan (instead of the bagels, pizza, peanut butter and other “free” foods in the hospital) for a week or two. I promise you’ll feel better, learn better and have more energy to take good care of your patients.
“With rare exception, the majority of surgery residents and practicing surgeons who prematurely leave surgery do so because they find the work to be physically, emotionally or spiritually incompatible with the vision they have for their life.” Am J Surg 214:707, 2017
I’ve read a great deal about physician wellness, suffering and burnout and I’ve given (and heard) many talks on the subject. The classic talk on burnout, including some of my early talks, can be summarized as “Exercise more, eat well, pay attention to your family and friends.” I am in no way belittling these things as important, but…. as a good friend said to me the other day “If I have to hear one more lecture on burnout that tells me to add an hour of exercise, an hour to plan and cook my meals and an hour to meditate to my already crazy day, I’m going to shoot myself!”
Not too long ago, a friend recommend I read A Bigger Table: Building Messy, Authentic, Hopeful Spiritual Community by John Pavlovitz. He was in Houston yesterday, and I was able to go hear him speak. John is a Christian pastor, but his words and ideas can be used by everyone, regardless of whether you are religious or not and, if you are, regardless of the faith you hold
John’s idea, which is neither doctrine nor theology, involves creating a “bigger table” in our lives, a table that has the four “legs” of radical hospitality, total authenticity, true diversity, and not having an agenda.
It’s human nature to surround ourselves with people that are just like us. But, when we only include people like us in our lives, our potential for growth and happiness is limited as a result. I truly believe that this “small table” mentality contributes to physician suffering and burnout, which means that the idea of building a bigger table may be just what we need.
So, what might a “bigger table” look like for physicians who are struggling with the “why” of their practice?
Radical hospitality. Dr. Francis Peabody famously said that “the care of the patient is in caring for the patient”. The same holds true for our colleagues, patient families and everyone around us. If we cultivate an appreciation, even love, for these people – regardless of how difficult they are or how much we disagree with them – we are practicing radical hospitality. As in so many of the gifts we give to others, this is a gift to ourselves, too.
Total authenticity. We all need a place to be absolutely, completely ourselves… unfiltered, loved, totally accepted. I’ve always told my trainees that the single most important factor in choosing where you practice is the people you will be joining. There is no location, salary or title that will ever make up for working with people that don’t let you be truly, authentically you.
True diversity. This is not just diversity in the sense we are used to hearing about. In addition to religion, race, gender, age and sexual orientation, true diversity means accepting and listening to people that have totally different views than you. Ouch.
During his talk, John told the story of “Sign Guy”. He was having lunch with a gay teenager when they noticed a man outside the window. He was carrying a sign that said gay people were an abomination and that they were going to hell. The young woman asked John “What about ‘sign guy’… how do I invite him to my table?”
We all have “sign guys” in our lives that, like it or not, we should invite to the table in order to have true diversity, but (and this is really important), we have to agree on “table manners” first. Which brings us to the fourth leg of the table…
Agenda free table. The concept of the bigger table is that we are choosing to sit at the table together because we know the power of listening, the power of really understanding each other. Although we can and should invite everyone to the table, no one should stay who is intentionally trying to change or hurt someone. Being agenda free is one of the non-negotiable “table manners” for all who want to sit at a bigger table.
So how do I think this translates this into our day to day work? For a start…
Spending more time learning the stories of our patients… not just “taking their history”.
Working to see administrators and leaders as people who care like we do… not just defending our specific point of view.
Calling out the agendas and implicit biases that keep us from hearing the soft voices of colleagues who are young or discounted for other reasons.
Checking back the next day to be sure that a colleague who said he’s “fine” really is.
Doing all this even though it’s hard, especially when it comes to the “sign guys” in our lives.
I’m sure there are others… what would you add?
“Grab some wood and some tools, friend. We have work to do.” John Pavlovitz
Today I have the incredible joy of talking to the medical students on our rotation. No agenda, just a conversation that they requested for some “advice”. They just started their surgery rotation last week and it’s their first rotation. First rotation, beginner’s mind, unbridled enthusiasm… it is so wonderful!. I decided I would come up with what I wish someone had told me at the beginning of my rotations…
Be mindful, deliberate and excited about learning.
This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.
Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat, keep on a piece of paper in your wallet or on your wrist
Learn about the practice of mindfulness. Mindfulness has been shown to be effective in decreasing stress and may help to prevent burnout. It’s not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)
Learn to keep a “beginner’s mind”. When I was a student on core medicine I had a senior resident that showed me what beginner’s mind looks like. It was 2am and I was tired. We were seeing a gentleman at the VA hospital for his diabetes, hypertension and some electrolyte abnormalities. I presented the patient to the resident and then we went to see him together. He had a rash, which I thought was so insignificant that I didn’t even include it in my presentation. But, instead of scolding me, this resident got excited. Yes, you read that correctly, 2am and excited about a rash – because he didn’t know what it was. (This next part will date me, but it’s a great example to make us grateful for the access we have to information now). He called security and had them open the library. We spent a wonderful hour looking through books – like a treasure hunt when we were little kids – until we found the rash in one of the books. We were laughing, excited and couldn’t wait to get back to start the appropriate therapy.
Understand what you are going to learn (the big picture)
On every rotation, you will be given a list of learning objectives. By all means, know them, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).
You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.
Develop a system for lifelong learning now
Learning is iterative. You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema. If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.
The practical points on how to develop a system to learn during your rotation are here: How to Ace the NBME Shelf Exams: How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards, but the key points are summarized below:
Take care of yourself.
Pay attention to ergonomics, diet, exercise and sleep. Most importantly, take care of yourself emotionally and spiritually. You can’t learn or serve others if your tank is empty. Come up with what is important for you and make a list. Seriously. Make a list of what you find helps you stay on track and then check it off every day. Look at it before you go to bed. Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.
Don’t forget to take a “Sabbath” every week. True time off is critical for recovery from this stressful work.
If it gets too hard, seek help. It’s a sign of strength, not weakness, and most (if not all) of the people around you have been there.
We have the most amazing job on earth. When the administrative issues or political conflicts get to you (and they will), just remember – you get to take care of another human life with the goal of relieving their suffering. What could be more important than that?
The other day, while I was looking at my Twitter feed, I came across this amazing thread by Dr. Jennifer Cowart. I was so moved by this heartfelt plea to our elected officials that I asked her permission to post it here.
I have never seen a patient who did not deserve healthcare.
I have seen people, rich and poor, who do not take care of themselves. Who drink too much, eat bad food, smoke, use drugs, drive recklessly, etc. If you smoke and get lung cancer, or if you didn’t smoke and get lung cancer, you deserve healthcare.
I have seen people, rich and poor, who believed themselves entitled to whatever care they wanted, at whatever cost, whether it was evidence-based or not. It didn’t change the fact that they deserved appropriate healthcare.
In fact, it is interesting that “entitled” is an epithet more often thrown at an “undeserving” poor person than a rich person with the same behavior and attitude.
I treat “good” and “bad” people. People I wouldn’t let in my house. It doesn’t matter. I’ve treated registered sex offenders. I don’t ask what they did. I take care of their pneumonias, their heart failure, their cirrhosis. They deserve healthcare. My care.
I took my (healthy, neurotypical) baby to a specialist the other day. We passed many children with (visible) special needs. A girl with a trach in a push chair. A teenager escorted by her father with CP. Children with various genetic syndromes. They deserve healthcare.
That could have been us. If not for the luck of genetics, my children could be those children. Blessings, but also requiring significant care, time, money, and resources. Those children are worth as much as mine and deserve their healthcare.
To me, the fact that it will cost a lot of money to ensure everyone has healthcare coverage is secondary to the fact that everyone deserves it. If we decide everyone deserves it, we will finance it. Expensive things can be worthwhile. Healthcare is one of those things.
I have seen cancer patients lose their insurance and not know where their care will come from. Chemo regimens interrupted. Radiation not given. “Lost to follow up.” I have been in those rooms, held those hands, wiped those bitter tears.
When you’ve worked your whole life, had private insurance, got cancer before you are old enough for Medicare, get too sick to work, lose job, lose insurance, have to wait for disability/Medicaid to kick in… this is pain like you haven’t seen. Those people deserve healthcare.
I know there’s the flipside. People who never worked. Maybe they really were truly lazy, or maybe they were caretakers and never worked outside the home (doing invisible work). Some of these folks are rich, some poor. I treat them all.
Illness doesn’t respect your work history. “Bad behavior” may increase risk of bad outcomes, but we transplant a lot of livers into cirrhotics who drank. Cancer strikes a lot of folks who never smoked, who got HPV from their spouse, who did nothing “wrong.”
The only category I see that we consistently say as a country who doesn’t “deserve” their care are the poor. Sure, people judge alcoholics or people dependent on opioids, but we haven’t made huge moves to dump all of those folks off their healthcare programs.
Yet Congress tried to cut millions of people out of Medicaid. Give them the “freedom” to “choose” their care—which they can’t afford. They didn’t cut smokers off, or alcoholics, or diabetics who eat sugar, or heroin users. Just poor people, those “undeserving.”
We are still waiting for CHIP to be funded. Guess who’s children are covered under CHIP? Not the kids of smokers. Kids of working people who don’t make much, but earn too much for Medicaid. In other words, people who don’t have enough $ to “deserve.”
I reject the premise that money is what makes you worthy of my time and care. I understand that healthcare must be financed. My time is not free. I am not a volunteer. But if you have pneumonia, my worry is not how will you pay, but how to treat you.
So figure out how to pay for it, because everyone deserves to get treatment for their special needs child, their cancer, their pneumonia. To get that treatment, and not be bankrupted by it. Everyone deserves basic healthcare.
Jennifer B. Cowart, MD works as a hospitalist in Jacksonville, Florida. She is a graduate of the The University of Texas Health Science Center at Houston and trained in Internal Medicine at Baylor College of Medicine followed by a fellowship in Clinical Pharmacology and Hypertension. She then served as the Chief Resident in the Quality and Patient Safety (CRQS) program at the Michael E. Debakey Veterans Affairs Medical Center.
I’m not a great fan of New Year’s Resolutions in general. Like all of you, I’ve made them and broken them more years than not. But that being said, I do think the new year is a time we should pause and take account of where we’ve been and where we want our journey to lead us. Or, put a different way, we can use the transition to a new year to think about who we are and who we want to become.
So instead of the usual resolutions to lose weight, drink more water, exercise, etc – here are three “resolutions” for medical students, residents and physicians that may be easier to keep this year. (If you aren’t in medicine, I think they still apply.)
Deliberately reset your intention to be kind with every encounter you have with patients or colleagues. Don’t forget to be kind to yourself, too.
Keep up with every day tasks so they don’t weigh you down.
Clean out your medical records, record your cases, prepare food for the next day… whatever it is that will free up time and emotional energy. Make a list of these tasks with check boxes and keep it on your phone so you can see it often. Clear the list every night to start over for the next day. Celebrate what you accomplished during the day and have self-compassion for the things you weren’t able to do.
Take care of yourself – physically, emotionally, spiritually.
Be deliberate in the choices you make to take care of yourself. Don’t get overwhelmed by the pressure of wanting to do it all. Know that some days will make it hard to exercise, eat right, be still, etc. That’s ok, but don’t give up. Make sure you do something for your own wellbeing every day.
The gift you give to others through your career is special – remind yourself often of the amazing work you do. Take measures to sustain your career so you can continue give to others and have joy doing it.
I wish for you all a New Year filled with kindness, peace, and joy!
After passing through this year’s holiday season at the end of what has seemed a particularly difficult year, I have a great sense of hope for the new year.
In addition to our usual understanding of the word “hope”, it turns out that hope is also “a sloping plain between mountain ridges.” I love this definition…. so maybe hope is also the moments when our journey is a little easier between the times we are climbing?
I wish joyful hope for you in the coming year, mountains to climb for the right reasons, and sloping plains to ease your journey when you are tired. Happy New Year!