“Do you think it would be ok if I…?”

“We had a graduation celebration, but it was smaller than usual… only 20 people… and the older people just stayed a little while.”

“We meant to stay socially distanced… but you know kids.”

“God will protect me… I don’t need a mask.”

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Oh, how I wish this were over. We all do.

And it will end.

It will end, but what we have to grapple with now is how many of us will die unnecessarily before it ends… because the rest of us “had to get our hair cut” or thought this was some kind of political “hoax”… or just couldn’t be bothered.  

Because I am a physician, I have a lot of friends and family who call to ask some version of “Do you think it would be safe if….” I usually respond by telling them what I’m doing and then answer questions as they try to figure out the changes they need to make to be safe.

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I am in awe of how much we have learned about how the virus spreads in aerosols, how it stays on surfaces and how very infectious it is. We owe a huge debt of gratitude to the scientists who have tackled this pandemic with heart, mind and soul. This knowledge is guiding us, protecting us, and is essential to save lives.  

So, with gratitude for the science that has helped us better understand #COVID19, here’s what I tell my friends and family we are doing when they ask….

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Stay Home. We stay home unless it’s for an essential need. For example – we would go to the dentist for a painful tooth (but not for a routine cleaning). We have supported our local restaurants with pick up or delivery, but we don’t go to restaurants yet. When we do, it will only be outside and only if we are sure CDC guidelines for restaurants are being followed. There is no way we would go inside for a movie, rally, worship or other public gathering. The data are more than clear… large gatherings inside are the highest risk activities right now.

I get our vegetables from Pierre at a Plant It Forward farmer’s market sponsored by Dandelion Cafe. (I’m mentioning them on purpose because having these just picked vegetables has been a true gift!) But I have the rest of my groceries delivered. I ask the delivery person to put them on the step (by text). I wear a mask, and don’t open the door until they are more than 6 feet away to thank them. (BTW, they are doing amazing work to keep our communities safe – please tip often and as much as you can).

One of the questions I get asked about staying home is “but I’m young… isn’t it ok for me to go out?”. The answer is yes and no. Younger people are less likely to die or develop chronic lung disease from COVID19, but it’s not impossible. Here’s the real issue – If you end up infected with COVID19 you’ll infect people around you that are at high risk… and they could die or have horrible outcomes from the disease. Do you really want to risk hurting your grandparents or that nice guy at the store who always says “Hi” to you? Think about creating a “quarantine pod” as an alternative to going out to restaurants, bars and concerts… it’s not going to be the same, but it’s a good compromise to keep socially connected while being as safe as possible.

Photo credit (and great post on why “Zoom fatigue” is real)

Do it virtually if you can. If we are asked to run or be in a meeting, we do everything possible to make it virtual. If you are in charge of gatherings, this is an important responsibility. There is no reason to expose any of your colleagues or employees unnecessarily.

I’m an academic surgeon. I can’t do surgery virtually, but I can do a lot of clinic visits by video. I can do all my group teaching and committee meetings by Zoom. There is no moral justification to have meetings in person if they can be done online and I’m happy, as someone who can decide, to make sure my students and colleagues aren’t exposed to more risk than necessary.

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Socialize outside. If I am meeting a friend (or friends) I’ll only do it outside and only if we have discussed in advance how to manage the event. I’m excited that this weekend I’m going to an outside workshop that FAMHouston is facilitating to teach refugees how to grow vegetables in container gardens. These are my friends, so I really want to see them! We have established in advanced that we will meet CDC guidelines with everyone in masks and more than 6 feet apart.

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#WearYourMask. If I’m around anyone, I wear a mask, and I ask them to wear one – AND we stay at least 6 feet apart. The masks only come off if we are outside and more than 6 feet apart. It’s also really important to wear it properly! In particular, if your nose is hanging out, you might as well not have it on. Two other important things: 1) A face shield alone is better than nothing, but isn’t as protective as a mask and 2) the masks with the “breathing valve” aren’t worth wearing. Remember, my mask protects you. Your mask protects me. That’s why if we all wear masks we can stop the spread of COVID19!

Exercise with a mask available. When I’m outside exercising, I have a cooling mask (it is Houston, after all!) around my neck. As soon as I see someone coming towards me, I pull up my mask. I get a good 20-30 feet beyond them before it comes back down.

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Bring your own glass. I had a friend over for a glass of wine on the back porch not too long ago. They didn’t come through my house (and I would do the same for them). I opened the gate to the backyard, and they walked through my back yard to the back porch where I met them. They brought their own wine glass. We sat on opposite sides of the porch, 10 feet away from each other and had a wonderful, soul healing visit.

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Assume if someone else has touched it there is COVID19 on it. It’s a long shot, but what if… the UPS driver has COVID19 but is asymptomatic, coughs on their hands, picks up the package they are delivering … and now you pick it up. One inadvertent rub of the eyes at that point could easily mean an infection.

We put an old towel on a table and designated that table as “contaminated.” We put new packages on the table and immediately wash our hands. (If you work in an OR, you will understand this well… if you touch something contaminated you “rescrub” i.e. wash your hands before touching something else.) This sounds complicated but it’s not… if it’s just been handled by someone else, we assume it’s contaminated.

We have found that it’s easy to leave things on the table for 3 days before we open them (surprised us, too!). Obviously, groceries that need to be in the refrigerator are a little different (they get put in new plastic bags which go into the fridge). And, because three days may be long for some items…bottles of beverages get washed with soap and water before they go in the fridge.

Now, I have to be honest. A lot of new data are coming out that says we may be on the far end of safe with this. Some surfaces clearly are more at risk (like door handles), but things that get delivered are probably not really a problem. This is one to figure out your comfort level, stay up to date on the new info, and come up with a reasonable plan.

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I hope this helps.

Whenever I am tempted to say “just this once” … or fall into the trap of feeling like it can’t really be “that bad” to meet without masks, I think about how all my colleagues are putting their lives on the line to care for infected people… and how I would feel if I were the one responsible for their death, or the death of someone I know and love.

Be safe and take care of each other.

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#EyesOpen

Like you, I’m surrounded and sometimes overwhelmed with the fears and anxieties of the COVID19 pandemic. The world seems so very fragile and vulnerable right now. This morning was tougher than usual for some reason. So…. I got out of my chair, put on my shoes and went for a walk trying to look, with eyes open, for things to sustain me, connect me and provide solace.

Here’s what I heard on my walk …

A virtuoso mockingbird singing to the world (and, I assume, a few cute nearby mockingbirds), six different languages from people walking near me (I love Houston!)… friendly “hellos” from almost everyone I passed (all more than 6 feet away)…

Here’s what I saw on my walk…

A magnificent tree that I had never really noticed before… a family rescuing a caterpillar from the street with a stick… small purple flowers in the grass… kids on bikes… a butterfly garden in a “pocket” prairie…

Here’s what I learned …

Fear is gone when gratitude is present. They can’t be present at the same time.

It’s therapeutic to spend a little time with your #EyesOpen, preferably outside.

If you are a healer, thank you for what you are doing and stay safe. I’ll hold you in the light.

On the Twelfth Day of Christmas….

Did you ever wonder why Christmas is on December 25th? … or why we decorate pine trees if Jesus was born in the Middle East? To make the long story short (while begging forgiveness from my theology professors for the oversimplification), it has to do with the Roman Empire adopting Christianity as the state religion in the 4th century. When the Romans moved to conquer what is now England and Germany, the people they were conquering were more than a little reluctant to give up their celebration of the solstice and their understanding of the wonder of trees…. so the two religions “merged”, allowing these symbols to become part of the Christian tradition.

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And what about the 12 days of Christmas? Christmas (the religious holiday, not the shopping season) starts on December 25th and ends twelve days later on January 6th (Epiphany)… hence 12 days.

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As I thought about the holiday season, and the 12 days of Christmas, I came up with a different idea to celebrate this season… What if we all started a new tradition of donating a small amount to worthy groups for twelve days?  

I’ve listed twelve of my favorite charities below, but feel free to come up with your own. Even if you donate a few dollars to each one, you are celebrating the season of Christmas, Hanukkah, Kwanza and the Solstice in a powerful way.

  1. Doctors Without Borders (Médecins Sans Frontiers). This amazing group takes medical care into parts of the world where no one else will go. Their entire charter is worth reading, but they live by “observing neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance.”
  2. Your local food bank. Whatever preconceived notion you might have about hunger in America is almost surely wrong. So many families, Seniors and disabled folx rely on food banks. Make this year a time to learn more about hunger in America and donate to feed your neighbors.
  3. A local animal shelter. Kindness to animals is the mark of a compassionate heart.
  4. Neighborhood initiatives. Regardless of your own religious background, or lack thereof, mosques, churches, temples, and synagogues seek to help those in need. Find the places of worship in your neighborhood,  look online to see what good works they are doing, and donate to help them. Better yet, take your donation in person to meet your neighbor and thank them for their work.
  5. Donate to help fight discrimination and oppression. There are so many important groups working for justice, a particularly important mission during this time of conflict and division. Consider donating to the Southern Poverty Law Center, the Human Rights Campaign, RAICES, Human Rights Watch, the ACLU or other groups focusing on justice for all.
  6. Action Against Hunger.  This group spends 94% of the money they raise in 47 countries to “take decisive action against the causes and effects of hunger.”
  7. The National Alliance to End Homelessness. You can also donate to local shelters for the homeless, or programs like Healthcare for the Homeless in your town or city.
  8. Prevent Child Abuse America. As someone who works with abused children, I would also encourage you to donate to the chaplain program at your local children’s hospital. The chaplains see the specific needs of these children – but more often than not don’t have resources to provide meal vouchers, toys or clothes to help a family during these moments of tragedy and pain.
  9. Consider donating to a group that is working to stop climate change, or other groups that advocate for and protect our natural resources such as the American Bird Conservancy or the Nature Conservancy.
  10. Make sure an isolated senior has a visitor and food by donating to Meals on Wheels.
  11. Time. If you don’t have money to donate, make a commitment to volunteer with a local group to help others. “You make a living by what you get. You make a life by what you give.” ~Winston Churchill
  12. I am personally involved with FAM Houston (consider this my COI declaration!), a group that inspires me through their mission of “working for justice by building empowered community among refugees, immigrants, and local Houstonians.” Through building friendships and creating community they show that any light, no matter how small, is a miracle of love. If you are in need of a worthy group for your twelfth day of Christmas donation, please consider them!

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Last minute holiday gifts for busy people in your life

There’s still time!

If you have a medical student, resident, physician or anyone who is super busy in your family, here are few last minute gift ideas for you….

A Letter

I’m starting with this one because even though it’s obvious, we forget the power of stories in our lives to heal and support each other. Consider writing a long letter with stories about how they inspire you, when they decided on their career, funny events, etc.  Stress joy, humor… and gratitude.

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Spotify and/or Pandora without commercials

Many of us study with music, and most of us work (at least sometimes) with music in the background. These two platforms are currently the most used in the hospital. Being able to listen to the music of your choice without commercials is a great gift!

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InstantPot

Of all the cooking appliances and gifts, this one is the best for people who want to eat well but don’t have a lot of time. Even if you have to wrap the “IOU” (i.e. a picture of the InstantPot), it will be a very appreciated gift!

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A clean home

No one likes to clean their home, but all of us need this!  Even if it’s a deep clean every 3 months for a year, this is a great gift for anyone. Although there are professional services you can find, consider contacting local places of worship or non-profit organizations who may know responsible individuals who need the work.

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A subscription to Headspace

This one might seem a little strange, but you’ll have to trust me. For anyone who is “too busy” this is an easy way to really stop – even for 10 minutes a day – and “refuel”. BTW, get yourself a subscription (or at least try the first 10 lessons which are free). You’re welcome 🙂

Link to Andy Puddicombe’s TED talk (the founder of Headspace)

Other ideas for gift certificates

  • A healthy grocery store
  • A smoothie or juice shop
  • Their favorite restaurant(s)
  • Car wash
  • Starbucks (or even better, a local coffee shop near them)
  • Prepared healthy meals from one of the many companies that do this now
  • Membership to the YMCA or a gym near them
  • A new bicycle? (we never get too old to love this!)
  • “Date night” certificates for movies, plays or music and a meal
  • A favorite museum

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Anything Can Be A Prayer

I Happened to Be Standing

Mary Oliver

I don't know where prayers go,
     or what they do.
Do cats pray, while they sleep
     half-asleep in the sun?
Does the opossum pray as it
     crosses the street?
The sunflowers? The old black oak
     growing older every year?
I know I can walk through the world,
     along the shore or under the trees,
with my mind filled with things
     of little importance, in full
self-attendance. A condition I can't really
     call being alive
Is a prayer a gift, or a petition,
     or does it matter?
The sunflowers blaze, maybe that's their way.
Maybe the cats are sound asleep. Maybe not.

While I was thinking this I happened to be standing
just outside my door, with my notebook open,
which is the way I begin every morning.
Then a wren in the privet began to sing.
He was positively drenched in enthusiasm,
I don't know why. And yet, why not.
I wouldn't persuade you from whatever you believe
or whatever you don't. That's your business.
But I thought, of the wren's singing, what could this be
     if it isn't a prayer?
So I just listened, my pen in the air.

Why I’m Thankful for #ThisIsOurLane

Tomorrow is Thanksgiving, so today I’m with my family, looking at the timeline for tomorrow and discussing when the pies need to go in, who is making the cornbread and calculating how long the turkey needs to cook.

As of today, there will be 12,996 families in the United States who lost a family member to gun violence in 2018…. almost 13,000 Thanksgiving tables with an empty seat from a preventable death – from this year alone.

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Late at night on November 7th, the NRA posted this on Twitter:

I, and many other physicians responded as soon as we saw it…

My second tweet was followed by a long thread of PubMed abstracts with research results showing how we might start decreasing deaths from gun violence. The NRA, interestingly, removed all of those Tweets from their timeline.

#ThisIsOurLane has become a movement. A callous Tweet from the NRA started it, but that’s not what is sustaining it now. As I discussed in this podcast, I think what the NRA did was make physicians realize that this “debate” is not about politics, it’s about lives… human lives… sisters, brothers, mothers, fathers, friends. It’s about our patients and, unfortunately, our colleagues. As a result of what has happened since November 7th, physicians have realized we need two things to move this forward: stories and data. Human beings are not swayed by debates, they are moved by stories. Good decisions can’t be made on emotions alone – we need data and that means research, and funds to do that research.

What you can do to help:

  1. Support important groups working to address gun violence as the public health problem it is. Donate today to Affirm (American Foundation for Firearm Injury Reduction in Medicine), Giffords, The Coalition to Stop Gun Violence, The Brady Campaign, Moms Demand Action for Gun Sense in America.
  2. Commit to questioning what you hear – from both sides. Question whether the fear created by the NRA is to serve another, more political aim… one that you might not completely understand or agree with. Ask questions. Ask for data. Recognize and ignore political rhetoric (from both sides). Keep an open mind.
  3. Support the funding of research into gun violence. Contact your representatives to let them know this a priority for you. This is no different than what we did as a society when we looked at death from car crashes… and developed seat belts, stronger cars frames and air bags. Wouldn’t it be great if we could see the same decrease in gun deaths through research?

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  1. If you are in healthcare, tell the stories in a way that respects your patients and their rights… but tell them. If you are on social media, use that platform. Until people realize that these are our siblings, parents, colleagues, and not just statistics, we won’t make progress. We have to move hearts before we can move minds.

I am so thankful for my family, for the opportunity to gather at the Thanksgiving table together, and for the many friends and opportunities that have been given to me. My heart goes out to all families who have lost a loved one to gun violence, including the horrible loss of life by suicide. May you find some small solace in knowing that we are holding you in the light – and that we will continue to work hard to end the tragic epidemic of gun violence in our country.

Photo credit (and info on the new initiative to stop gun violence from Toms.com)

Study Tips for First Year Medical Students

Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!

Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive

The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.

Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.

So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.

Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”

The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?

The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized?  (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)

This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.

  • SURVEY to get the big picture
  • QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.

During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.

*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)

After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.

Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language.  The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts.  That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)

Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!

Did I already mention that you need to review?

This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph.  First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.

Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later.  More is better.  Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!

 

Another thing about our brains and learning.  Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.

Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.

People sitting next to you in your study areas are going to look like they have it more together than you do.  It might be true… but it probably isn’t.  If someone has a study technique that looks like it will work for you, by all means try it!  Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,

Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.

Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.

It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.

I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.

Welcome to the best career in the world! We are all happy you are here!

 

 

 

 

 

The Ripple Effect

Dr. Marc Rowe is one of the truly great pediatric surgeons of our era. His work in newborn physiology profoundly changed how babies were and are taken care of in intensive care units. His prolific research, along with the many people he trained, has unquestionably affected the lives of hundreds of thousands of newborns.  He has taken on creative work as a writer and wood carver in his retirement. Dr. Rowe is one of my personal heroes and, when I read this essay he recently posted, I asked his permission to post it here to be able to share it with you.

Photo credit and link to video

I am troubled by what is happening to our Country. Principles and ideals – truth, honor, kindness, diversity compassion and love and protection for the people, the creatures and the environment we share has been replaced by selfishness, prejudice, lies and a willingness to compromise in order to gain material wealth and power. What is particularly frightening is the effect the current leadership may have on our greatest gift, our children- the message sent – that you can be dishonest, unfaithful to your loved ones, lie, be a racist, a bully and a braggart and still become the most powerful person in the world and be supported by many of our religious and political leaders. I am confused – does this mean that these political and religous leaders would choose our current president to be a role model for their children and grandchildren?

As I watched this sad period in the history of our country unfold I was overtaken with a sense of powerlessness. I then remembered two lessons I learned during my career as a pediatric surgeon. The first occurred during my first job as an assistant professor of surgery. I was incensed by an episode of academic politics and was tempted to speak out but realized if I did I would pay a price. I vented my frustration to my wise and famous boss, Dr. Mark Ravitch, a battle scarred warrior of the political and academic world. He said – “before Socrates drank the hemlock he began his defense by saying –never let it be said that I had a podium and failed to speak. – You have a big mouth use it”.

The second lesson came later when I became depressed realizing the huge number of children suffering from potentially correctable diseases and abnormalities and how little one person could do. I then began to think about the ripple effect – the ever-expanding effect that even one person can have by teaching and striving to be a role model. I realized that young people are astute observers and learn not by what their teachers say but by the way they act, how true they are to the principles they teach and most important by not selling out when being principled becomes painful and dangerous. Kids spot phonies a mile away.

Three people I have greatly admired, Mother Teresa, the Dalai Lama and Robert Kennedy all have spoken of the ripple effect. To quote Robert Kennedy who spoke of the ripple effect during the tumultuous civil rights strife – “Each time a man stands up for an ideal, or acts to improve the lot of others, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”

This carving I call the Ripple. The pond and thrower is carved from a branch and cross-section of bass wood, the shoreline is made from Sanibel sand and the stone in the pond is a small piece of river rock.

Scientifically Superstitious

There is a longstanding superstition in medicine that you never wish someone a quiet call night, sort of the medical equivalent of never wishing an actor a good show. We are trained in science, so all physicians know this is silly…and yet…

There are many theories in psychology about why human beings are superstitious, but the one that I think best explains the superstitions of doctors is that superstitious rituals decrease stress and can improve performance during stressful work.

So, don’t make fun of me when I wear my green socks for Kasai procedures… or when I feign horror if someone wishes me a quiet call night!

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