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.

 

Lamentation for the Lost

Like so many others, I can’t believe the hatred and evil that has manifested itself in Orlando, Louisiana, Minnesota, Dallas, Nice and Baton Rouge.  I grieve with the families and friends of those who lost their lives. I embrace those who are devoting themselves to healing this hatred and the wounds it has caused.

As someone who teaches embryology I can tell you that all of us – no matter what race, religion, sexual orientation, or gender are fearfully and wonderfully made. We all start as one cell and become human beings through an amazing dance of cells that become eyes to see, hearts to beat, arms to hold and brains to understand and love. There are no differences between us until we are born and labels are applied.

As a surgeon, I can tell you that all blood is red.  I also can assure you that all hearts break equally when faced with hatred, loss or grief …. and all souls soar with birth, healing and love.

May we all become healers in this time of sorrow.

hatewontwin (2)Photo credit

 

What Big Magic Can Teach Those Who Serve

“Do what you love to do, and do it with both seriousness and lightness.”*

kidsPhoto credit

On the flight home yesterday I finished Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert (She’s probably known to you for her NY Times Best Seller Eat, Pray, Love). For me, one of the overarching messages of her book was this – When you see what you do as your vocation (from Latin vocātiō, meaning “a call or summons”), and not just your job, it will transform how you view your work – a concept which I believe may be necessary (but not sufficient) to treat or prevent burnout.

As I read her thoughts on how to live a creative life, I realized that there were other ideas  that applied to physicians, physicians in training and others who serve:

 

Just show up. Every day.

“Most of my writing life consists of nothing more than unglamorous, disciplined labor. I sit at my desk and I work like a farmer, and that’s how it gets done. Most of it is not fairy dust in the least”

Learning and practicing medicine (or any other field) means showing up – really showing up – every day. Everyone in the first year of medical school learns that it is different than college. Cramming for exams is not only ineffective, it’s just wrong. You are no longer studying for a grade on a test…. it’s now about the patients you will take care of in the future. The same holds true during residency and when you begin your practice. It’s not just when you are a trainee.  Part of the “work” of medicine remains “unglamorous, disciplined labor”… keeping up with the literature, going to teaching conferences when you could be doing something else, finishing your hospital charts, being on call.

But the work of medicine is also about showing up every day in another sense, too – truly showing up for the people who rely on you – no matter what. That, too, can be “unglamorous, disciplined labor” when you are tired or stressed.

“Work with all your heart, because—I promise—if you show up for your work day after day after day after day, you just might get lucky enough some random morning to burst right into bloom.”

Inspiration+is+for+amateurs_chuck+close+quotePhoto credit

 

They are your patients… from the first day of medical school until you retire.

Most of all, there is this truth: No matter how great your teachers may be, and no matter how esteemed your academy’s reputation, eventually you will have to do the work by yourself. Eventually, the teachers won’t be there anymore. The walls of the school will fall away, and you’ll be on your own. The hours that you will then put into practice, study, auditions, and creation will be entirely up to you. The sooner and more passionately you get married to this idea—that it is ultimately entirely up to you—the better off you’ll be.”

Caring for others gives us joy but also gives us the responsibility to know the best thing to do for them. Whether you are a first year student, 3rd year resident or a PGY35 attending, we are all still learning. “Life long learning” is not just a phrase, it’s the reality of what we do.

real lifelong learningPhoto credit

 

It’s called the practice of medicine for a reason.

“It’s a simple and generous rule of life that whatever you practice, you will improve at.”

Learn the art of deliberate practice early. Deliberate practice, to use a musical analogy I learned in Cal Newton’s fantastic book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, doesn’t mean playing the piece from start to finish 20 times in an hour. It means spending 55 minutes on the small section that you struggle with, repeating it 100 times before you play the piece through once. It means instead of reading the comfortable material on the anatomy of the kidney, you deliberately tackle how the nephron works. It means that instead of doing the computer-simulated cholecystectomy 10 times you spend an hour tying intracorporeal knots in the trainer. Find the thing that is not easy and practice it over and over until it becomes easy.

pianoPhoto credit

 

There is Peril in Perfectionism

“There are only so many hours in a day, after all. There are only so many days in a year, only so many years in a life. You do what you can do, as competently as possible within a reasonable time frame, and then you let it go.”

One of the greatest attributes of those who care for others is their devotion to the people they serve. But perfectionism, taken to its extreme, is dangerous. Extending your time to study for Step 1 beyond what is reasonable to try to get a higher score, revisiting decisions about patient care to the point of anxiety, worrying that your GPA has to be perfect are all counterproductive. The motivation to do well is like a cardiac sarcomere – a little worry will make you more effective, but stretched too far, there won’t be any output at all.

Starling curvePhoto credit

 

Curiosity can overcome fear.

“No, when I refer to “creative living,” I am speaking more broadly. I’m talking about living a life that is driven more strongly by curiosity than by fear.”

It’s something most students don’t realize, but no matter how long you practice medicine, there are days when you are afraid. It takes courage to do what we do. Remember, being courageous is not an absence of fear, it’s being able to do what’s right despite the fear. I agree complete with Elizabeth Gilbert that curiosity helps. When you have something that doesn’t go the way you expect or frightens you, instead of beating yourself up (“I should have studied more”….”I could have made a different decision”…etc…etc) become curious. If you are thinking about a complication, commit to finding everything you can about the procedure and how to prevent complications. If you didn’t do as well on your test as you thought you should, look up different techniques to study, take notes, and remember information, and go back to make sure you really understood what was being tested.

Even more powerful than curiosity is gratitude. Fear and gratitude cannot exist at the same moment. Try it – the next time you are about to snap because your EMR freezes be grateful that you can see the computer, be grateful you have work, be grateful you have been trained to help other human beings …and see what happens.

“We must have the stubbornness to accept our gladness in the ruthless furnace of this world.”

thank youPhoto credit

 

Your worth is not the same as your “success”.

“You can measure your worth by your dedication to your path, not by your successes or failures.”

Wow…. This one is so important.

It’s not what you make on Step 1. It’s not how many cases you do, how many patients you see or how much money you make. This concept is taught by every religion and philosopher I know – for a reason. Be devoted to doing the best you can and to forgiving yourself (and learning from it) when you fall short.

dedication to pathPhoto credit

 

One last thing….for medical students trying to choose a specialty – forget about finding your passion.

This is a little longer quote than the others, and mirrors a similar message in So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love .

Find something, even a little tiny thing, that makes you curious (or fills you with wonder) and follow it. Dedicate yourself to following that curiosity and it will likely lead you to your career.

“May I also urge you to forget about passion? Perhaps you are surprised to hear this from me, but I am somewhat against passion. Or at least, I am against the preaching of passion. I don’t believe in telling people, “All you need to do is to follow your passion, and everything will be fine.” I think this can be an unhelpful and even cruel suggestion at times. First of all, it can be an unnecessary piece of advice, because if someone has a clear passion, odds are they’re already following it and they don’t need anyone to tell them to pursue it…..I believe that curiosity is the secret. Curiosity is the truth and the way of creative living. Curiosity is the alpha and the omega, the beginning and the end. Furthermore, curiosity is accessible to everyone…..In fact, curiosity only ever asks one simple question: “Is there anything you’re interested in?” Anything? Even a tiny bit? No matter how mundane or small?….But in that moment, if you can pause and identify even one tiny speck of interest in something, then curiosity will ask you to turn your head a quarter of an inch and look at the thing a wee bit closer. Do it. It’s a clue. It might seem like nothing, but it’s a clue. Follow that clue. Trust it. See where curiosity will lead you next. Then follow the next clue, and the next, and the next. Remember, it doesn’t have to be a voice in the desert; it’s just a harmless little scavenger hunt. Following that scavenger hunt of curiosity can lead you to amazing, unexpected places. It may even eventually lead you to your passion—albeit through a strange, untraceable passageway of back alleys, underground caves, and secret doors.

 Listen to your heartPhoto credit

 

*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!

 

 

Yes, I’m a Surgeon and Yes, I teach Mindfulness

At the most recent ACS Clinical Congress, I was really struck by a presentation on mindfulness given by Sharmila Dissanaike and asked her if she would be willing to write about the topic for wellnessrounds.  To my delight she agreed!

 

chen_600

Photo Credit

The recent #Ilooklikeasurgeon phenomenon reminded me that times do indeed change – albeit slowly. The peak of this phenomenon happened to coincide with my talk at the American College of Surgeons on “Mindfulness for Stress Reduction and Burnout Prevention”. If you had told me 10 years ago that I would one day deliver this brief lesson in stepping off the treadmill for a few moments, I would have said you were crazy. Surgery was only for the tough, and the tough don’t need breaks (or so we thought). As a woman surgeon, it was even more important to me that no chinks show in the armor, and being a trauma surgeon proved an easy way to solidify my “street cred” despite being a 5”2’ little brown woman with long hair.

So it has taken a while for me to feel confident enough to broach such a “soft” topic in a public surgical forum. Obviously age and (a little) wisdom has probably helped, but there is also a tangible change in the prevailing culture of surgery as exemplified by the #Ilooklikeasurgeon movement and other similar initiatives; where calling for help is no longer an (automatic) sign of weakness, and the surgical community has accepted that the good old days (or bad old days, depending on your perspective) are well and truly over. The next generation of surgeons is currently being greeted with much hand wringing and wailing and gnashing of teeth, for how could a group of kids raised in this limited workhour era possibly achieve the heights of excellence that the “old school” surgical residents achieved? Since the switch to 80-hour workweek happened exactly midway through my residency, I have the privilege of a foot in both worlds, and while I agree that our training paradigms do have to change, I am not yet ready to concede that the golden age of surgery is well and truly behind us. Partly, this is because of the audience that gathered for the session at ACS. What stunned me even more than the opportunity to speak on mindfulness was the full house that gathered for this session, and the enthusiasm and interest generated by a wonderful audience of men and women of all ages, and in nearly equal proportions – it embarrasses me to admit that I had expected to be speaking to a handful of younger female surgeons. Instead, I met the 65 year old broad-based general surgeon who came because he recently lost a younger orthopedic surgeon colleague to suicide – by stabbing himself through both femoral arteries, with surgical precision of course. I met several Governors of the College, who were in the classic “grey haired” demographic, and yet optimistic and enthusiastic about the future of surgery, and the improvements to be had by focusing more on our wellness – that “healing the healer” would have tangible results not just for our own wellbeing but also that of our families and our patients, and was thus an obligation, not an option. I met young surgeons a few years out of residency/fellowship who had already recognized the need for maintaining their own mental health in order to remain functional for as long as possible in order to maximize the productivity to be gained from their long training – working less was certainly not on their priority list. There was clear recognition of the systemic problems that drive a lot of surgeon frustration with ensuing burnout – bureaucracy, being treated as interchangeable expendable cogs in a machine, electronic medical records and endless paperwork topping the list – and yet there was also an acknowledgement that adjusting internal cognitive factors was at least as important for wellbeing as it was to try and change some of the external factors.

The methods I teach are focused on building resilience and capacity – characteristics that are both innate and learned, which can be developed and expanded through meditation and other techniques. One of my favorite analogies is that a spoon of salt in a cup of coffee renders it immediately unpalatable; the same spoon in a river or swimming pool would not be noticed. The spoon of salt represents the unavoidable daily irritants in our lives – the cases that run late, the scrub tech who doesn’t know what instruments you use, the colleague who lets you down in a key meeting. The cup of coffee of course is us – or at least, where most of us start. Instead of spending our lives either trying to avoid all these frustrations (which is futile) or becoming upset when they happen, mindfulness can increase our capacity to be with them fully, accept them for what they are and yet respond thoughtfully and effectively instead of blindly and automatically reacting with anger or frustration (which usually only causes us more trouble in the long run). Over time, we develop an increased capacity to handle irritation without it placing us in a perpetual bad mood, and increased resilience to bounce back from the inevitable traumas of life, both personal and professional.

So why teach mindfulness to surgeons, when there are plenty of other things I could be doing that would probably be more directly beneficial to my career? Because I do believe that the biggest waste of potential is to take a motivated young person, put them through the grueling training to be a surgeon, set them out on a career that is of such benefit to society, and then allow them to flounder and become discouraged 5 – 10 years later, quickly discarding those hard-earned skills as they turn into full time administrators, wound care docs or some other alternate career path. Not that there isn’t value to these professions of course, and some people do realize at a late stage that they are better suited to another path – in which case all of these are excellent choices. But too often it is one bad outcome that leads to a malpractice suit, or some other event that proves just too difficult to handle, that completely derails an otherwise excellent surgeon and this lack of coping – the lack of capacity, and resilience – leads to a complete abandonment of what should be an intrinsically rewarding career.

If mindfulness, meditation and other strategies can help even one surgeon regain a wider perspective and avoid this outcome, then it will have been a worthwhile endeavor.

AR-130109974.jpg&MaxW=468&q=100

Photo credit

Dr. Dissanaike is a general surgeon with primary focus in trauma, burns and critical care, and a Professor at the Texas Tech University Health Sciences Center in Lubbock, TX. She serves as Medical Director of the Level 1 Trauma Center and Co-Director of the regional Burn Center. She has an interest in ethics and humanism, and is on the ethics committees of both the American College of Surgeons (ACS) as well as the American Burn Association.

Resilience, Grief, and Remarkable Wisdom

My heart breaks for Sheryl Sandberg’s loss of her husband … and I am so grateful for her honesty, her wisdom and for the effort it took to share her journey. As I read her post on Facebook today, I realized that all of us in medicine could benefit from her thoughts as she ends sheloshim, the Jewish 30 days of mourning for the loss of a spouse.

One of the things that is so hard to teach in medical school (and all other health professions) is to honor the resilience of those we accompany on their journey through times of struggle and loss.  It is so hard to let go and realize there is nothing to “fix” in these situations. Far more important than trying to convince our patients, their families or our friends that it will be “better” or that there is “hope”… we need to commit to just being there with them, and walking with them on this very human… but incredibly hard journey.

“I have learned that I never really knew what to say to others in need. I think I got this all wrong before; I tried to assure people that it would be okay, thinking that hope was the most comforting thing I could offer. A friend of mine with late-stage cancer told me that the worst thing people could say to him was “It is going to be okay.” That voice in his head would scream, How do you know it is going to be okay? Do you not understand that I might die? I learned this past month what he was trying to teach me. Real empathy is sometimes not insisting that it will be okay but acknowledging that it is not. When people say to me, “You and your children will find happiness again,” my heart tells me, Yes, I believe that, but I know I will never feel pure joy again. Those who have said, “You will find a new normal, but it will never be as good” comfort me more because they know and speak the truth.”

Thank you for your wisdom, Sheryl.   We will hold you in the light.

Rabbi David Wolpe: What Sheryl Sandberg’s Post Teaches Us

800px-Golden_sunrise

Photo credit

“We are all just walking each other home.”  Ram Dass

Compassion: Lessons from Roshi Joan Halifax

It’s not often that a talk completely changes the way I think about something.

I’ve been thinking and speaking about compassion fatigue for many years.  I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.

We can never have too much compassion nor can true compassion result in fatigue.  

compassion hands copy

Photo credit

Empathy and compassion are not the same thing.

Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.

compassion joan halifax

Link to Roshi Joan Halifax TED talk “Compassion and the true meaning of empathy”

Self-regulation is the key to being able to remain compassionate and this skill can be taught.

We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences.   How you respond to this state determines whether you can stay present, effective and compassionate.  Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.

G:  Gather your attention. Take three deep breaths.  Be present.

R: Recall your intention.  We choose careers in medicine to help heal the sick and to reduce suffering.  It’s not easy to remember this intention when we are overwhelmed.  But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.

A:  Attend to yourself.  Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy.   After gathering your attention and recalling your intention, pay attention to what is going on in your body.  Watch your breath, feel where there is tension, pay attention to sensations.

C:  Consider what will really serve.  Moving from empathy to compassion is defined by considering the actions that will relieve suffering.  Really consider the person and the situation and decide what is most likely to improve the situation.

E:  Engage ethically.

“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.”  Joan Halifax

compassion heart in room copy

Photo credit

Starting Internship (I know what you are worried about)

I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them:  Will I kill or hurt someone?  Will I look stupid?  What if they find out I’m not as smart as everyone else?  Will I get divorced/separated/alienated from my friends?  Will I gain weight?  How am I going to find time to take care of myself?

Scared_Doctor

Drawing credit

What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way.  The best way to manage your (healthy) fear is to have a strategy.   I’ve written in the past about how to succeed as an intern.  But if I were going to condense that advice into three easy rules (for every day except your day off)  it would be these:

1.    Read at least one section from a textbook in your field every day

2.    Learn something (in detail) from at least one patient every day

3.    Do something to take care of yourself every day

Read at least one section from a textbook in your field every day.

Your goal for the year should be to read a major textbook in your field cover to cover.  You don’t have to buy the physical book.  It’s fine if it’s on line or downloaded onto your iPad.

Once you have the book, make a list or spreadsheet of all the sections in all the chapters.  For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics.  When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).

The real goal is not just to read these topics, but to really learn them.  So, when you read, don’t just skim.  Read to learn.  That means taking notes – and reviewing them.

Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.

Photo credit

Learn something (in detail) from at least one patient every day.

It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service.  Make it a daily habit to learn in detail about one patient in your care.  It will overlap nicely with your goal to read a complete textbook.  When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.

One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher.  When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself.  Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents.  They’ve been there.

Photo credit

Do at least one thing to take care of yourself every day.

This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day.  At a minimum, though, pick one specific thing you are going to do for yourself and then do it.

Eat well

Get Some Exercise

Be social