I had the honor of speaking at the American College of Surgeons this week on a panel about stressors clinicians have control over i.e. can modify. I was assigned a topic I had not really thought about before – which meant I learned a lot! After the talk, there were many people who came up to me and asked if they could have my slides… so here they are!
This is a really important concept… worry is an intrusive thought, which means it just pops in your head. And it’s unpleasant, so you worry about worrying!
Another important point here – worrying is always about something in the future (as opposed to rumination, which is always about the past)
These are the two main ways worrying helps us – motivation and emotional buffering. The motivation part is pretty obvious. Emotional buffering is also obvious, but I didn’t have a name for it before. Take for example worrying that you will fail a test. If you end up getting a good grade on the test it is somehow even more exciting… but, if you do poorly your disappointment is somehow buffered.
In terms of emotions, control is the opposite of worrying. Take the test I mentioned above. If you are worried you will fail it, the way to deal with that is to regain a sense of control. For example, using smart notes to optimize learning during your rotations, using this plan to ace your in-servce exam, or this plan to get ready for exams during basic sciences.
This principle holds true for ALL clinicians – no matter how long your have been in practice.
And then I tackled the next question… what to do when worry begins to spiral.
I introduced this validated tool to see if your worrying has crossed the line to problematic or pathologic.
And pointed out that if worry is causing you to suffer, it’s a problem.
The way to deal with problematic worry is to try to return it to the kind of worrying that helps us, which we can do with any action to control what we are worried about. Worried about a test? Make a plan for how and when to study. Worried about a relationship? Plan to meet or pick up the phone to talk. Again – no matter what your are worried about – do something to create a plan to address the worry.
But despite our best efforts, the spiral of worry can land us in a bad place. If you find you have anything on this list (or if you are really suffering), it’s pathologic worry.
It’s super important that you act – quickly. This is your amygdala trying to hijack your brain! (Remember flight-flight-freeze?) If you don’t derail it quickly, it will continue to spiral and land you in a world of anxiety. In other words, follow all the steps for problematic worry – but if it doesn’t work, don’t wait. Get help.
New interns and their more seasoned senior residents are asked this almost every day. So let’s talk about this for a minute and what that question really means…
What you are being asked to do.
The hospital requires a signature on a consent form (always printed with very small font and several pages long). This part of the consent process that has a long history guided primarily by legal counsel for hospitals and, yes, you need to get the signature. But…
There are five things that must be present for informed consent. If any of them is missing, it’s not informed consent.
The patient must have the capacity and ability to understand. (No intoxication, translation when needed, etc).
The patient must actually understand. (This means you have to confirm they understood with a conversation – Can they explain it to another family member? Do they have questions?)
The person performing the procedure (or their designee) must describe the procedure and must discuss alternatives, risks (and how likely they are) and the expected benefits (and how likely they are).
The patient has to agree without coercion. (If you aren’t sure about this, don’t proceed)
There are questions that every intern would like to ask about this process but can’t/won’t. Here are a few that come to mind…
What if you’ve never performed (or even seen) the procedure yourself? It’s hard to get truly informed consent if you aren’t competent in doing the procedure. But – you know (intellectually) the alternatives, the potential risks and benefits, and the “big picture” of the procedure. Particularly for complicated procedures, you can assume that the attending has discussed these (and therefore is the person who actually got the consent!). Here’s a way to make this easy… “Hello, I’m Dr [xxx}. I know that Dr. Attending has already talked to you about your surgery. I’m here to go over the alternatives, risks and benefits again – to make sure you don’t have any questions I can take back to Dr. Attending for you.”
p.s. If you are “Dr. Attending” in this scenario, you are the one who is ultimately responsible for the informed consent (and liable if it’s not done properly).
Is it important to get the consent just before the procedure? No, in fact it makes it legally more sound and much more efficient to document informed consent when you first see the patient. For elective or semi-elective surgery, it takes no time at all for “Dr. Attending” to put this phrase (or one like it) in their clinic (or ED) note: The procedure including alternatives, risks, and benefits was discussed with the patient, all questions were answered, and informed consent was obtained. This documentation often holds more water than the signed form (at least according to most attorneys I’ve talked to). Best yet – do both. Get the consent form signed at the same time! It’s easy to scan into the medical record to be there for the day of surgery, which is a win-win for almost everyone involved.
What if It feels like you are scaring the patient/family when you review the list of the possible complications? First of all, that’s a normal feeling. But we have to learn to handle the anxiety that is always part of this process. In addition to trying to be really calm and supportive, here’s how I handle that: “When we decide about doing surgery, we always ask which is riskier… to do it or not do it. For you, we’ve decided together that it’s risker not to do the surgery… which is why you are here. But because there are risks, I want to make sure you understand them and we can talk about them before the operation.”
What if they don’t speak English but the family says they can translate for you? It’s not informed consent unless it’s translated into their language by a professional medical translator. Imagine the shoe on the other foot. What if your best friend the artist was travelling in a country where none of the doctors or nurses spoke English and they needed surgery? They would be terrified and so would any family member who was with them (even – or maybe especially – if they were being asked to translate). Don’t cut this corner. Please.
Isn’t this blog post oversimplified?
Yes!
Informed consent is a fascinating and rapidly changing area of medical ethics. I hope I’ve hit the critical highpoints and addressed a few unspoken questions many trainees have, but it’s unquestionably a “30,000-foot view”.
p.s. If you have more questions, even ones that seem naïve, please comment on this post or email me (if you don’t want them to be public).
It has been said that the Inuit people have a hundred words for snow. When you live in a dangerous environment, it’s important to learn the variations of snow to survive. But, when you look into the origin of the “hundred words for snow”, it turns out it’s not exactly true – Inuits don’t have more words for snow than other languages…Their detailed understanding of snow is a lived, not spoken vocabulary.
The same is true for those who spend nights awake working in a hospital. We, too, have a lived vocabulary that includes hundreds of subtle variations of fatigue, even though we don’t have words to describe them. (The closest I’ve come to being able to describe this fatigue is in “sleep equivalents”, specific events or things that makes you feel like you have had more sleep than you actually did. For example, a shower after being up all night can give you the equivalent of anywhere from 20 to 60 minutes of sleep depending on how tired you are. Brushing your teeth after a hard night of call is usually 5-10 minute sleep equivalent. A good strong cup of coffee can be as much as 45 minutes of sleep equivalent – although it’s important to titrate it so you don’t end up with anxious jitters instead of just being awake.)
Knowing how to manage this level of fatigue it is part of medical training. (Don’t get me wrong… I’m not advocating that trainees must get tired on a regular basis to “learn how to manage it”) Learning to successfully manage the fatigue of long days and nights on call hinges on two things and both have to do with deliberate choices.
Learning not to trust your first instinct if you are sleep deprived is the first important lesson. Even if it’s a drug you know well, or the chest x-ray looks ok, stop and be deliberate. Consciously review the data, look at the options and, for really important decisions, ask someone to look at the situation with you.
The second lesson in managing fatigue is maybe even more important. The bone deep fatigue of medical training is not solely the result of sleep deprivation. When you stay up all night you also lose the liminal spaces of waking and falling asleep, the threshold between night and day. In scientific terms, this means there is a major disruption of your circadian rhythms. But it’s more than just physiology. The drowsy moments between sleep and being awake take place in the liminal spaces of dawn and dusk. We lose more than orientation to daylight when we lose this liminal space. The Irish poet and priest John O’Donoghue, teaches that liminal spaces are moments and places where the spiritual touches the finite. By losing the profoundly important rhythm of rest – including these liminal spaces – we end up physiologically, psychologically, and spiritually unmoored.
You have to be deliberate here, too. By trial-and-error work to find the things that ground you, the things that help you recover in a deeper way than just catching up on the sleep. Make lists of anything and everything that helps you recover from call for the times you are too tired to remember or choose. Look at those lists before you leave for your call day and choose something to do for yourself when you leave the hospital the next day. It might be going to the gym for a light workout, having a great cup of coffee in a cafe, a slow, grateful walk outside, playing with a pet, a hug from a loved one…or finding a way to “play” outside.
May the sacrifice of time and sleep you make for others come back to you as joy … and may you find deep rest in knowing you make a difference in so many lives.
What if I told you there’s a system that makes it easy to remember the things that you need to remember for exams, but also creates links that make it easy to study and understand the network of knowledge that you really need to learn to heal?
And what if you could start using this system beginning on the first day of medical school…or at the beginning of your PGY2 year… or wherever you are on this journey now?
Mine is labeled “card file”. You can always rename it. Maybe start with “My digital brain”?
If you just can’t stand it, you can create sub folders based on an anatomic filing system (e.g. Appendix, Colon, Heart, etc) but trust me – no sub-sub folders!
*I like Google Drive because it’s very flexible and you can access it from any computer and your phone. There are other ways to store digital data that can work as well, like Evernote, OneNote, etc.
Keep a notebook in your pocket, use paper out of the printer, use a white board, or dictate directly into Google drive… but just take notes!
This practice is a leap for most of us, but it not only leads to phenomenal learning, it fundamentally transforms how you interact with your day. There is power in a practice that makes you more present in your day. Every encounter, every lecture, every article you read becomes a potential adventure, a source for new insight and growth.
There are only two rules
Rule 1: One concept per note.
Rule 2: Write the note only one time – don’t rewrite or retype notes. (If its’ a paper note, take a photo, or create a pdf to file in your google drive.)
What kind of notes will go into this system?
Lectures. You know how to do this from other classes! Just because we call it “Grand Rounds” or “Path-Rad conference” doesn’t mean it’s not a class. Take notes!
SOP (Standard Operating Procedure). This one is key if you are in a procedural specialty. Keep a single “note” for each procedure and update it with new information as you scrub with new attendings. Put in links to good videos, photos from textbooks and anatomy books. Anything that will help you review what you know and have learned before you do the procedure again.
Milestones. The first time you….listened to a murmur, talked to a patient about their prognosis, did a Whipple.
Questions, thoughts… “Why isn’t there a way to diagnose malrotation that needs surgery (vs.nonrotation) with diagnostic imaging?”
What you learned from patients. Make it your goal to learn something from every patient you take care of. Write it down. Make sure it’s HIPAA compliant – no patient identifiers that someone else could decipher.
Sounds. Yes, you can digitally store recordings!
Summary Notes. One page summaries of complex ideas
Unanswered questions. Ideas for possible publications, future investigations, etc.
There are so many details in medicine that we often lose track of the big picture. That takes thinking, creating one page summaries of complex topics, and noticing connections.
Maybe it would be easier to show you rather than tell you. Let’s say you are in a lecture about how to read a chest x-ray. In your notebook (or on your computer) you are taking notes… lots of notes… how to tell what’s a pneumonia vs atelectasis, what different lung tumors look like, how to tell if the mediastinum is too wide. As a result, 2 years from now when you see a patient with a lung mass, you will be able to search your drive for “lung cancer” and these specific notes will come up.
But as you sit and think about this lecture, you’ll realize that in addition to the details, there were more general concepts that were important, too. For example, how important it is to systematically review every diagnostic image so you don’t miss the lytic lesion in the bone that was behind the big mass in the chest. (Link to my favorite study describing how this happens)
So you create a digital note that describes, in your words, how important it is to have a system to look at images. Which makes you remember that this is very similar to how we always follow a system to do a history and physical. So you search in your drive for the card you made about how to do an H&P and you link them, using the “insert link” command. And, as you look at your H&P card, you notice that you had already linked it to cards you made about Basic Life Support (BLS) and ACLS (Advanced Cardiac Life Support), two certificates you were required to obtain, both based on a system to not miss important steps in resuscitating patients. And suddenly you are interested in why systems like this make it so much easier, so you do a quick search and find a fascinating article on memory and learning (as opposed to memorizing).
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!
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).
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)
“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.
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.
