The socioeconomic issues we face today aren’t new, so maybe it’s not a surprise that we struggle to even imagine a world where hunger, homelessness, and illness are faced with kindness and equity… which is why I was so intrigued with this article by Swapan Samanta, an economist who uses mathematics to understand social inequities.
“They [the prophets of five major religions] knew that food is never just food, that meals reveal the soul of a civilization, that the way we eat together – or fail to – determines whether we survive or collapse. Ancient wisdom and modern mathematics point to the same truth…Scarcity is a choice, not a condition.”
For those not in medicine… the ductus arteriosus is a one of the necessary shunts around the lungs when babies are in the womb. (You don’t want blood going to the lungs which can’t oxygenate the blood because the baby isn’t breathing yet.) At the moment of birth, all that has to change… and pretty quickly. In term babies, it starts immediately, and the closure is done by 48-72 hours. In premature babies, it can take longer. And, in rare cases, it doesn’t close at all. When it stays open, we call it a patent ductus arteriosus (PDA).
Since the first surgical closure in 1938, PDAs have been closed by surgery, catheters, and medications. Over the last several decades there has been a progression in which way was the “right” way (and when it should be done). To summarize the overall trend, we began to move away from surgery and towards less invasive catheter and/or pharmacologic closure. Like all good research, there were lots of studies that preceded and led to the work published this week – which showed that just waiting (without medicines, surgery, or catheter closure) had the same outcome (a composite of death and/or bronchopulmonary dysplasia at 36 weeks) when compared to using medicines to close the PDA. Importantly, it also showed that the overall death rate was less in the babies who were just observed.
No difference in early death or lung disease, and a higher survival without any direct treatment.
Caring for those who are ill or injured is a 24 hours a day job, 365 days a year… including the holidays.
Being on call during the holidays comes with a little sadness, but it’s complicated. If you’ve ever worked in a hospital during the holidays, you know it’s special in a way that’s hard to describe. Somehow everything seems a little gentler. Even though everyone working would like to be home, they also realize it’s even more true for the patients…. especially if they are children. Kids in the hospital at Christmas tug at the heartstrings of everyone except the very few not-yet-transformed Grinches or Scrooges (and even they are not immune).
But it’s not just doctors and nurses, it’s everyone working during the holidays whose work helps to make others whole… because healing isn’t just about procedures, medications, and diagnosis… it’s about making others whole. In fact, the word literally means “to make whole”.
Old English hælan “cure; save; make whole, sound and well,” from Proto-Germanic *hailjan (source also of Old Saxon helian, Old Norse heila, Old Frisian hela, Dutch helen, German heilen, Gothic ga-hailjan “to heal, cure”), literally “to make whole” (from PIE *kailo- “whole;” see health).
Police officers, fire fighters, EMTs, paramedics, 911 dispatchers, social workers, counselors, clergy all work to decrease suffering and heal. So do the people who clean, cooking, answer phones, or do anything to make that healing possible.
So Merry Christmas, Happy Hanukkah, Happy Kwanzaa, and Joyous Solstice to all who are working over the next few weeks… and all who support them in this work. All of our winter celebrations have one thing in common… celebrating light coming into a world that struggles with darkness, light that heals.
If you are working during the holidays, thank you for being that light.
p.s. My family makes this cranberry bread every year for Christmas. It’s delicious, makes your house smell incredibly wonderful, and (BTW) is a fabulous way to say “Thank you!” to a healer in your life who is working during the holidays.
Mix dry ingredients together in a bowl:
2 cups flour
1 cup sugar
1/2 tsp salt
1 1/2 tsp baking powder
1/2 tsp baking soda
Combine in a Pyrex measuring cup:
2 Tbsp melted butter
Juice and grated rind of one large orange
Fill with boiling water to make 3/4 cup then add to dry ingredients. Then add the following to the batter
1 egg
1 cup nuts (chopped walnuts)
1 cup raw cranberries (cut in half)
Bake in loaf pan (325° for metal pan, 300° for glass pan) for 1 hour
Test with toothpick
p.p.s. If you are particularly motivated to bake and give some away to neighbors and friends multiplying by 9 is the key to easy measurement:
Mix dry ingredients together in a bowl:
1 5 lb bag flour
1 4 lb bag sugar
1 1/2 tblsp salt
4 1/2 tblsp baking powder
1 1/2 tblsp baking soda
Combine in a Pyrex measuring cup:
1 1/8 cup melted butter (2.25 sticks)
Juice and grated rind of nine large oranges
Fill with boiling water to make 6 3/4 cup then add to dry ingredients
Add 9 eggs
9 cup nuts (chopped walnuts) = 3 lbs
9 cup raw cranberries (cut in half) = 3 12 oz bags
Bake in loaf pans (325° for metal pan, 300° for glass pan) for 1 hour
Get in shape, meet new friends, AND help the environment?
Screengrab photo from here which I learned about here
Spogomi is a new “sport” where teams of people compete to pick up as much litter as they can in a specified time period.
“Some 53 million tonnes of plastic waste and 4.5 trillion cigarette butts are discarded on streets and landscapes globally each year. Japanese runner Kenichi Mamitsuka began scooping up some of them on his morning jogs in 2008, and soon hit on the idea of gamifying his public-spirited act to raise awareness of littering.” From this article
Cash to pay to talk to your doctor after hours?
“My father was on the phone for a long time with the nurse in his primary care doctor’s office working out a challenge with the timing of his various medications. They accidentally got cut off, so he called back… just after 5pm. The phones had been automatically transferred to the answering service and he was told that if he wanted to talk to someone he would have to pay in cash.”
I asked a few questions to make sure I had heard the friend telling me this story correctly (since I couldn’t believe what I had heard…)
Have you experienced this or know someone who has?
The size of life
I hope you enjoy this amazing work as much as I did. Thank you Neal Agarwal and Julius Csotonyi!!
I’ve always thought we missed a great opportunity in medicine for collective nouns… A flow of urologists? A clot of hematologists? …😂
Day Light Savings Time. It’s easier for your body clock to adjust when flying east to west through time zones which is why it is easier to adjust to the “fall back” to standard time that we just experienced. There are lots of theories about how daylight savings time got started and why. It’s also known that a) it’s better for us to not go back and forth between daylight savings and standard time and b) if we have to pick one or the other, standard time is the one to choose.
Eco Divina. Lectio divina is a powerful tool for meditation and/or prayer, a four step practice that uses the words of a text (usually a sacred text) to lead you to insight and inspiration. (If you haven’t ever tried it, here are some great instructions. Although these instructions refer to the Bible, any text, from sacred writings to poetry can be used. I had heard of visio divino, where art serves the same purpose… but eco divina was new to me (at least by that name). Like sitting with words, or with images, eco divina is sitting deeply with something in the natural world in a way that reminds you of the beauty of creation (and your part in it).
The moon. Make sure you go outside tonight and look at the moon. It’s a supermoon and worthy of a little “eco divina” (aka awe).
I love this app to know when the moon rises and sets (and in which direction).
The best hospital signage I’ve ever seen.
I was recently part of a survey team that visited Savannah Children’s Hospital and I have to share how patients and families find their way in their hospital!
There is a “tree” in the entrance that defines the color scheme for the entire hospital (green = surgery, brown = diagnostic imaging, blue = ER/ICUs…etc ). There are also symbols associated with each color.
(the family gave me permission to take this photo)
Then you follow the path!
Every corridor has tiles that confirm you are still going in the right direction based on the colors.
We often forget that 21% of adults in the US are illiterate, which means they won’t be able to read signs pointing them to different areas in the hospital (or any building for that matter). In addition to being incredibly effective, this attention to design is also an act of kindness.
Still thinking about Game 7 of the World Series…
I have never seen a game like it and probably never will again…
I recently came across the powerful concept of “hourglass learning” in this post by two professors who teach teachers and, not surprisingly, wondered how it might apply to teaching physicians and other healers.
That being said, if you love learning (or love someone who is trying to learn), these concepts can be applied at any age to anything – from bird watching to learning math!
Basic Sciences (Medicine taught in a classroom)
For basic sciences, the hourglass paradigm works well, but I added some practical points from the equally powerful SQR3 (Survey, Question, Read, Review, Repeat) system using a typical hour-long lecture and assigned reading as an example.
Survey (Establish a purpose).
It’s easy to forget that you don’t actually study medicine to pass a test… you are learning to heal, to serve those who need you. In that light, the first step – “establish a purpose” – can be thought of in two ways. The first is to set an intention, to remember why you are studying. And then, more specifically, to ask “What is the purpose of this lecture?” That’s where the tool of “surveying” comes in.
This is an exercise in curiosity not “studying”. Skim over everything to get the big picture. Look up words you don’t know (and their roots). Look at how the lecture is organized. Are there obvious sections? Are there lists that look like they will be important? Can you tell what the most important points will be?
Question (Extract evidence)
This is an interactive process that starts with your survey.
Before the lecture: As you are surveying make notes (on the slides, in the margin of the notes, or as a separate list) with what questions the lecture will and, more importantly, won’t answer about the topic.
During the lecture: Listen for and jot down the answers to the questions you wrote down the night before. If there are questions that aren’t answered in the lecture, ask the professor afterwards.
Read (Make sense)
After the lecture but on the same day (don’t wait!), add to your notes to make everything as clear and as organized as possible, look up anything that is missing, and then make a one page “30,000 foot” review of the lecture.
Review (Form meaning).
The 4th step is to return to the “why” by linking the lecture to how the information applies to actual human beings. Even though search engine AI may point you in the right direction, it should never be your sole source as a professional. (That’s in bold for a reason.) As a professional you need to make sure the information you have is vetted (i.e. peer reviewed).Start with PubMed or UpToDate to find a review article on the topic.
Repeat (Reproduce knowledge).
Real learning only happens with repetition, so setting up a schedule to review your notes with progressively longer gaps between reviews is the secret to success. This is where Anki or other similar systems can really help.
An important note on question banks… You can’t learn medicine from UWorld. (Again, in bold for a reason.) BUT, question banks are an awesome way to confirm you’ve learned the important stuff – and to identify where there might be some gaps. So please use them as an adjunct to, but not core of your studies.
Explain (Reproduce knowledge).
A great way to make sure you have “metabolized” what you are trying to learn is to share it with others. This is where study groups come in. They take as many forms as there are students, but in general, the most effective groups work as “out loud” reviews of the topics after everyone has spent time reading, reviewing, and repeating.
Teach (Share knowledge)
Teaching in the basic sciences is not as easy as in the clinics (other than “teaching” each other in study groups). But having a goal to to teach makes you organize your material in a way that insures you really understand it.
Rotations, Residency, Fellowship, and Practice (Medicine taught in clinic and hospitals)
The same “basic science” style of learning continues in clinical training, but there won’t (usually) be hour-long lectures or assigned reading. Instead, you’ll be seeing patients, attending conferences, and, yes, you will still be taking tests (shelf exams, in training exams, board exams, maintenance of certification tests, etc).
We want to and need to stay current in our field… but how? Here’s the best way I’ve found to do it, a practice that will serve you from starting rotations in medical school until you retire:
Find the most current and thorough textbook for your specialty
Make an Excel spreadsheet of every section/chapter
Set a goal (and make a plan) to cover the entire book in a year (which will look something like covering 12 sections/ week with weeks off for vacation and holidays)
Repeat every year! (It gets progressively easier after the 1st year since you are editing or adding to your notes)
Here’s the good news… Most of the 12 sections for the week (or whatever it works out to be for your textbook) will be chosen based on the patients you are seeing (It makes it a lot more fun…). The bad news is that all textbooks have really boring sections that still need to be learned, so spread them out over the year to make sure you cover them (but not all at once).
Repeat (Reproduce knowledge). Teaching and explaining on rounds is a built in way to make sure you understand enough to explain it to others. (Plus you look really good). This is where one page summaries and/or mindmaps really help since they make it easy to remember (and teach).
(Share knowledge) In clinical medicine, there are many opportunities to share … rounding, informal teaching for medical students on our rotations, formal lectures, presentations at conferences, handouts, etc, etc. Take advantage of this unique form of “group studying”!
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler
The definition of “knowledge” in English is pretty straightforward – To “know” something means being familiar and/or aware of it in a way that lets us understand. I find it fascinating that English has only one word for “knowledge”, where other languages use multiple words to reflect the depth and nuances of the concept. “Once widespread in Germanic, the verb [to know] is now retained there only in English, where it has widespread application, covering meanings that require two or more verbs in other languages (such as German wissen, kennen, erkennen and in part können; French connaître “perceive, understand, recognize,” savoir “have a knowledge of, know how;” etymonoline
How we understand “knowledge” affects how we teach, how we learn, and how we see the world.
The philosophers of Ancient Greece saw acquiring knowledge as an important part of the human quest for wisdom. Enter episteme, techne, phronesis, gnosis, and doxa. These nuanced ways to think about knowledge and wisdom have a lot to offer us as we navigate the misinformation and philosophical chaos of our time. For those in medicine, these nuanced definitions add beautiful complexity and understanding to our work, with special inspiration for those who teach the healing arts.
Techne refers to the technical skills of a profession – the grasp of grammar for a writer, pedagogical skills for a teacher, the ability to perform specific procedures for a surgeon.
I recently read this remarkable essay by Sami Sinada in which he states: “Medical school teaches episteme. Residency builds techne. But phronesis? We assume it appears through osmosis. It doesn’t.”
The entire essay is well worth your time to read, but Dr. Sinada makes an important point – Our medical school and residency curricula have gaps when it comes to teaching practical wisdom (which is the core of doctoring). He goes on to argue that we can close that gap with five important pedagogical choices:
What strikes me about doxa is that it has no moral weight associated with it. Doxa can refer to the deep orthodoxy of thousands of years of tradition in a culture … everything from how we greet each other to what we believe… as well as culturally accepted, politically motivated lies.
Gnosis is most often associated with gnosticism, a religious and philosophical movement in the 2nd century. But I wonder if the concept of a deep inner knowing (whether or not you view that as divine) isn’t worth refurbishing for our time as an important way to “know”. Contemplation, meditation, prayer can all open spaces that defy our intellectual understanding, leading to a way of “knowing” that, in some ways, we need now more than ever.
Let me tell you a story about an extraordinary recipe, one that had been handed down for generations, a recipe for meatloaf that was the centerpiece of every family celebration and holiday dinner.
On the day in question, those responsible for preparing the dinner realized that the 7 year old great-grandson was now ready to learn the family recipe. Needless to say, when they found him and told him they needed him in the kitchen so they could teach him to make meatloaf, he jumped up immediately and started running to the kitchen. His mother got a stool for him to stand on and an apron. She showed him the proportions of the different meats and taught him about the eggs and breadcrumbs. Together they combined the herbs and spices and then mixed everything together until it looked just right. Once it was the right consistency, she showed him how to mold it into a free-form loaf, cut an inch off each end, and place it in the oven to bake for an hour at 350 degrees.
He turned to her and asked the obvious question…
“Why do we cut an inch off each end?”
His mother looked up at him with a puzzled look on her face.
“I’m not really sure. Let’s ask your grandmother.”
The two of them went in to find her mother and asked the same question. Again, there was a quizzical look…
“I’m not sure either but Great-Grandma is sitting in the living room and it’s her recipe.”
They went together to find the matriarch of the family. She looked up as they entered the room and he started to speak…
“Grandma, I have a question for you.” She looked at him and he continued, “Why do we cut an inch off of each end of the meatloaf before we bake it?”
She started laughing and responded, “That’s how big my pan was!”
It’s not hard to find examples of the “meatloaf rule” in our personal and professional lives. Many of the incrementally small but steady improvements in medicine have been the result of someone saying… “Wait a minute…just why do we do it that way?”*
The same applies for our own well-being and growth. Some of the ways we’ve learned to be and act have been passed down for generations by our family and our teachers, but no longer serve us.
Here’s the practice: Look for examples of the “meatloaf rule” in your life. Use humor, use contemplation, use whatever works, but learn to recognize and then change the things that you were taught and now do automatically… but which no longer serve you.
*One of my favorite examples is how we have decreased the total days of antibiotics we use to treat appendicitis after folks asked if we really needed to do it the way we were always taught. We’ve gone from 2 touchdowns (14 days) to 1 touchdown (7 days), to stopping them when they are no longer helping (decided by a variety of signs and symptoms that indicate the patient has successfully conquered the infection). And yes, I meant touchdowns. It has always struck me as somewhat hilarious (and maybe a little worrisome?) that we give antibiotics based on (American) football scores.( 3,7,10,14,21). I know – It’s not really football scores. But having 5 fingers on a hand and 7 days in the week isn’t that much better of an explanation!
When is a blanket wrapped around your shoulders at 4am more than just something to keep you warm? Everyone who has worked all night resuscitating patients in the ICU, operating on emergencies that can’t wait, or caring for patients on the ward has experienced the chill that accompanies the normal 3-6 am drop in body temperature.
When we wrap a blanket around our shoulders or reach for a fleece vest to keep warm, in a way it’s just that… something to keep us warm in response to a normal circadian rhythm. But I can’t help but wonder if it might help to look at these garments as more than just a source of warmth.
The word “mantel” is a wonderful, old-fashioned word. It’s defined as “a loose sleeveless garment worn over other clothes”. The blanket over your shoulders when you get cold in the middle of the night is a mantel, as is your (usually Patagonia) vest. Perhaps replacing white coats with these vests isn’t the loss of symbolism we thought – if we can see them as a modern day mantel.
A mantel is more than just a garment – it is also a symbol of authority and power. This religious text is the source of the idiom “taking up the mantel”, which means to carry on the teachings and the authority of those who have passed on their skills, values, and wisdom to us.
The next time you get cold when you are up all night and you zip up your vest or grab a blanket to put over your shoulders, pause for a minute to consider this: We live in a volatile time, where many forces seem to be dismantling systems to the detriment of patients and their healers… if we don’t protect our patients and our trainees, who will?
“The covenant we make is not simply about how we will do a job, it is also about who we will be when we don the mantel of “physician.” It prescribes our conduct, calibrates our moral compass, and entwines both with our identity.” Wendy Dean
I never use AI to write, but I did use it for the banner photo. I’ll always let you know when I do.
I read a fascinating study1 this morning (thank you to @docmom61.bsky.social for the link!) For those in medicine, you know why this paper on call schedules and sleep deprivation is important … because you’ve lived it.
This study prospectively compared two groups of residents working in pediatric ICUs who were assigned to two different call schedules. The cool science here is that they modeled different schedules to choose which one to test against “the way we’ve always done it”.
The first group (EDWR) was, in effect, the control group, since they were put into a traditional Extended Duration Work Roster (24-28 hrs of continuous call with up to 88 hours/wk of total call). The other group (RCWR) was assigned to a Rapidly Changing Work Roster with variable lengths of call designed to limit extended call hours . (“…scheduled continuous duty hours limited to 16 hours (RCR-16) consisting of a short day shift (7:00-15:00), a long day shift (7:00-22:00), and a long night shift (21:00-13:00).”)
The RCWR is not a schedule I’ve seen before, but it does make sense. More importantly, it’s based on mathematical models, not fingers on our hands or days in a week!* For anyone who has seen the unintended consequences (emotional as well as physical) of the isolating night float system, anything new to consider is a welcomed alternative.
Here are my takeaways…
Total amount of sleep in the week (regardless of the schedule) was associated with less impairment. Focusing on more sleep is always the right answer if you are a physician, physician-in-training, or other healer.
It was a little easier to get more sleep on the RCWR schedule. The big picture here is that we need to be able to think out of the box when it comes to call schedules. Just because it has “always been this way” doesn’t mean it’s the right thing to do.
There was a lot of variability (for many reasons, all discussed in the paper) This is hard science to do, but important.
*Lest we think we choose numbers in medicine scientifically… have you ever noticed that we usually prescribe antibiotics based on American football scores? (Think about it… just where did our standard 7, 10, 14, or 21 days come from?)
On October 19th I used this blog to “post” slides during a talk (the two images and one table below) which everyone then accessed via their phones. I was speaking on a panel sponsored by the RAS (Resident and Associate Society at the Clinical Congress of the American College of Surgeons.) The overarching topic was “Sustaining a Career in Surgery” and, as usual, I learned more than the members of the audience… particularly by pondering two specific questions that were asked…
What does it mean when we talk about career sustainability?
When we talk about sustaining a career, most people frame that as how to keep going, how to not burnout, be injured, or worse. I’ve used the term “sustainability” a lot in my work as an educator, mentor, and leader in surgeon well-being… In fact, eight years ago I published an article entitled “Sustaining a Career in Surgery”. But this panel gave me the opportunity to think deeply about what we mean by “sustain”.
Here’s the definition of “sustain” from Merriam Webster Online: 1: capable of being sustained 2 aof, relating to, or being a method of harvesting or using a resource so that the resource is not depleted or permanently damaged b: of or relating to a lifestyle involving the use of sustainable methods
Read it again and realize… YOU are the resource this refers to… “a method of using a resource so that the resource is not depleted or permanently damaged.”
The goal is clear… we need to find ways to practice medicine that don’t deplete or permanently damage (physically, emotionally, and spiritually) those who strive to heal others.
Are sustainability and satisfaction the same thing?
To answer this second important question I referred to the image above – because Maslow’s hierarchy of needs answers this question and adds something very important.
Sustainability (not depleting or permanently damaging us) is about Maslow’s “basic needs”.
Satisfaction comes from meeting our psychological needs i.e belonging, feeling loved, feeling we are doing something that matters.
And then there is one more layer which Maslow called “Self-actualization”. This is what we really strive for and yet it is virtually never considered a metric we should measure (or at least talk about) when we discuss well-being.
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. doi: 10.1016/j.amjmed.2018.11.028. Epub 2018 Dec 13. PMID: 30553832.
If you haven’t read the article by Shapiro et. al, I highly recommend you do, because they translate Maslow’s ideas into the world of medicine. At the top of our professional hierarchy of needs, how we become “self-actualized” is our goal to “heal patients and contribute”.
Which let me to a different question, but one I think is crucial for us as individuals and for those who run the healthcare systems we work in…
