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!
“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?
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!
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.
As 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.
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.
“Do what you love to do, and do it with both seriousness and lightness.”*
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.”
“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.
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.
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.
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.”
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.
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.
*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!
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!
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.
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.