Do You Need a Bigger Table?

“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.

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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.

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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.

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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?


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 “Grab some wood and some tools, friend. We have work to do.” John Pavlovitz


How to Succeed in Clinical Rotations (and residency, too)

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…

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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

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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.

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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:

  • Remember it’s school.
  • Make a list of all the topics in the textbook.
  • Breathe deeply. You are not going to read every page in the textbook in addition to your assigned reading.
  • Create a schedule to SKIM every chapter
  • TAKE NOTES. All the time.
  • Figure out how to store your notes so you can find them in the future
  • Go through your daily notes in the evening and then store them in your system
  • Review, review, review

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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?

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Resolve To Be Kind

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.)

Be kind.

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.

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I wish for you all a New Year filled with kindness, peace, and joy!

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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.

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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!

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Top Ten Tips on Starting Medical School

Starting medical school is one of the most exciting moments in a physicians career… but it can be a little daunting!  This talk is one I gave recently to the college students in the Baylor College of Medicine Summer Surgery Program.  In addition to talking about how medical school is different from college, I also included my top 10 tips for successfully making this important transition.

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Advice physicians should follow. But don’t.

This is a truly wonderful piece from Emily Gibson, re-posted here with her permission from her beautiful blog, Barnstorming.  Enjoy!

octevening298As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our workload.  It is difficult to look forward to the dawn of the next work day.

Medical journals and blogs label this as “physician burnout” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead, we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.

Instead, we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days — interminably.

Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:

Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative, and it’s necessary.

Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.

Drink water throughout the work day.

Go to the bathroom when it is time to go and not four or even eight hours later.

Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.

Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.

Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.

Weep if you need to, even in front of others. Holding it in hurts more.

Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.

Learn how to say no gracefully and gratefully — try “not now but maybe sometime in the future and thanks for thinking of me.”

Celebrate being unscheduled and unplanned when not scheduled and planned.

Get away. Far away. Whenever possible. The backyard counts.

Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.

Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.

Start your work day on time. End your work day a little before you think you ought to.

Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.

Take a day off from caring for others to care for yourself.  Even a hug from yourself counts as a hug.

Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.