I had the honor of speaking at the American College of Surgeons this week on a panel about stressors clinicians have control over i.e. can modify. I was assigned a topic I had not really thought about before – which meant I learned a lot! After the talk, there were many people who came up to me and asked if they could have my slides… so here they are!
This is a really important concept… worry is an intrusive thought, which means it just pops in your head. And it’s unpleasant, so you worry about worrying!
Another important point here – worrying is always about something in the future (as opposed to rumination, which is always about the past)
These are the two main ways worrying helps us – motivation and emotional buffering. The motivation part is pretty obvious. Emotional buffering is also obvious, but I didn’t have a name for it before. Take for example worrying that you will fail a test. If you end up getting a good grade on the test it is somehow even more exciting… but, if you do poorly your disappointment is somehow buffered.
And then I tackled the next question… what to do when worry begins to spiral.
I introduced this validated tool to see if your worrying has crossed the line to problematic or pathologic.
And pointed out that if worry is causing you to suffer, it’s a problem.
The way to deal with problematic worry is to try to return it to the kind of worrying that helps us, which we can do with any action to control what we are worried about. Worried about a test? Make a plan for how and when to study. Worried about a relationship? Plan to meet or pick up the phone to talk. Again – no matter what your are worried about – do something to create a plan to address the worry.
But despite our best efforts, the spiral of worry can land us in a bad place. If you find you have anything on this list (or if you are really suffering), it’s pathologic worry.
It’s super important that you act – quickly. This is your amygdala trying to hijack your brain! (Remember flight-flight-freeze?) If you don’t derail it quickly, it will continue to spiral and land you in a world of anxiety. In other words, follow all the steps for problematic worry – but if it doesn’t work, don’t wait. Get help.
No matter how many times a pilot has flown a specific airplane, 100% of the time before takeoff, they review the SOP (Standard Operating Procedures) for that plane.
A while ago I realized that I prepared for complicated surgical cases by reviewing the same set of things every time – how to prepare the patient for surgery, the pertinent anatomy, the steps of the operation, potential complications (and therefore how to try to avoid them i.e. what to include in my informed consent), and post-operative care.
The day I learned about SOPs for pilots a lightbulb went off.
What if I did the same thing?
What if I took the books, articles, and websites I usually review, standardize the process, and create a single “living” document to review for every major procedure I do? It would be a document I could update as I got more experience – and as new findings and recommendations were published, too.
What I quickly realized was that the practice of creating, reviewing, and updating these surgical SOPs made me a better surgeon…and it made me a better educator. I could share my SOP for a specific case with the residents and students in advance – which let them prepare more efficiently for the case. I could also give the SOP to my anesthesia colleagues and the rest of the OR team to help them prepare, too.
The structure of my SOPs is more or less the same for any procedure and is demonstrated below with an example. Use it, modify it, or create your own… but if you are learning procedures as part of your medical training I strongly urge you to give this a try! The other piece of advice I would give you is to use a digital platform (like Google drive or EndNote) so you can access your SOPs from any computer and your phone. (Disclaimer: SOPs, like the one below, are only the starting point I use to prepare for a specific case. Since every patient is different, not everything below will apply to an individual patient.)
BTW – There is a decent time investment the first time, but after that it’s really a living document. Every time you have the privilege to scrub on the same case again, check PubMed, Google images, videos and update your SOP with what’s new before the case. After the case use it to make notes about different attending preferences and/or new information or techniques you learned from the case (but please be HIPAA compliant!).
The following is a guest post from my father, Professor Floyd Brandt.
At the time I decided to retire, I experienced two thoughts: First, I had been in a footrace for several years between retirement and obsolescence. The second thought was the closing line from Stephen Sondheim’s song Send in the Clowns — “Isn’t it rich, isn’t it queer, losing my timing so late my career.” Given the issue of obsolescence, I declared that my retirement was a trip from doing to being and then discovered that being is as challenging as doing, and often more so—learning to pause, meditate, and seek the joys of solitude requires new thoughts and habits.
Many, if not most, professors are inclined to think about what they would say in their Last Lecture and some even write it for the millions who will never read it and for students who will never remember it. My final lecture to my graduate classes could be divided into the pragmatic and the personal—I have included the pragmatic here:
After graduation, be your own professor. Keep asking questions. The quality of your life and the organizations you inhabit are dependent upon the quality of questions posed and answered.
During the interview with a potential employer, ask as carefully as possible, “What stories can you tell me about the company or organization”. If they have no stories, you may want to consider another company or organization.
As soon as possible, assemble a “Go to hell” fund equal to six months of salary available in case you need to refuse to engage in an unethical, illegal or extremely distasteful activity.
Attempt to locate the leaders in the organization who has real concern about defining the next decade.
Find out and then think about the years your boss was a teenager.
Begin to develop a flexible plan for the future. It is a truism that individuals and organizations that plan, seldom follow their plans, but they tend to perform better than those who do not plan.
Recognize the value of patience and silence. It usually takes a few years to achieve a top position in an organization.
We’ve all been there (yes, all of us). Something happens and we can’t stop thinking about it. It can be a complication, a misdiagnosis, something that happened in a toxic work environment, a failed exam, a harsh word. Not being able to let go of these thoughts means you are a normal person who cares… but it is not comfortable.
It will stop. At the time you are caught in the spiral of rumination, it seems unending. But it can’t and won’t last forever.
You are not your thoughts. There are your thoughts (and this annoying thought in particular) and then there is “you”. Hold that thought (then see below).
Don’t make it worseby yelling. It’s human nature to try to push an uncomfortable thought or image out of your mind. But it doesn’t work. Yelling at yourself (in your mind) because you are not able to move past the thought/event makes it even worse.
Get curious. Berating yourself makes it worse, but there is a way to disarm the thought and even make it go away:
When the thought arises, just notice it.
Wait….if “you” are noticing it, then the thought isn’t “you”.
Every single time the thought arises, say to yourself “I’m thinking about it again.” But – and this is the most important thing – when you notice that the painful thought is back, you have to notice it without judgment. Not… “I can’t believe I can’t let go of this thought.”…or “Something must be wrong with me.”… Just “There it is again.”
Mindfulness. The practice of noticing without judgment is called mindfulness. There are good data that an informal practice of mindfulness helps when we find ourselves with a thought that won’t let go. A daily practice helps even more. Set aside just 10 minutes and sit still. Just notice everything that comes up, acknowledge it, and don’t judge. Ditto for the next thought, and the next, and the next…
Here are some links if you’d like to learn more about mindfulness:
And we are all sick and tired of not seeing our friends….
So how do we decide if we should go to that big dinner or an out-of-town meeting in this complicated world of COVID-19? This is a classic ethical dilemma…and there is a tool kit* you can use to come up with an answer.
Step 1: Assess the information. What do you know and what do you need to know?
The first question to ask is “Who are the parties involved?” If you are deciding whether to go to an event, It clearly affects you and the other people who might be going to the event, but who else will be affected by the final decision?
The next two questions in this step are straightforward: What do you know? What else do you need to know?
Step 2: Think out of the box.
Every ethical dilemma has a “yes-no” answer, in this case to go or not to go to the event. But what other actions might be possible? Limit the number of people? Require testing and/or masks? Is there an option to participate virtually? This step should be a serious brainstorming exercise to explore ANY possible option (if you do it right, there will be some things on the list that sound almost crazy).
Step 3: Consider the Appeals
This is a fancy way of saying how do the possible choices fit with your values and what we, as a society, think are virtues?
Considering the appeals starts with a simple question – “Is there a rule?” For example, does your employer have a rule limiting travel during the pandemic? Are you traveling to a state that has a law prohibiting mask mandates?
The second question in this process is “What could go wrong?” What are the possible consequences of each option? If one option is to pay a little extra to be able to get a refund on your plane ticket, it’s probably not going to be important in making your final decision. But if it turns out that your decision might lead you to inadvertently infect your 70-year-old mentor with COVID, that’s more serious. Once you get a list of all the possible consequences try to put them in order of significance by asking if they are serious, irreversible, and/or likely.
The third question is “Which choices have more virtue?”. Which ones are more likely to reflect what we, as a society, think are behaviors and motivations that good human beings demonstrate? Most of us will agree that compassion, courage, self-sacrifice, legitimately protecting ourselves, integrity, and honesty are virtues, but there may be others that are important to you. Here is a link to see a long list of virtues to consider.
Step 4: Decide
It’s time to decide. Look at all the objective data (step 1), the list of possible actions (step 2), and which of the actions has the most virtue (step 3). Some of them will have more weight for you than others. That’s not only ok, it’s important. We may come to different conclusions, but using this process, we will both know why.
Step 5: What could have been done to avoid this in the first place?
This step won’t change your current dilemma, but it will help you and others with future decisions.
Let’s assume you’ve been invited to speak to a group next month. It’s an honor, and it’s a talk you love to give! But we are in the middle of a pandemic… should you say yes?
Step 1: Assess the information
Who are the parties involved?
You, the organizers, the people who will (or won’t) hear your talk, the people in your life you might infect if you get COVID, your work partners, the organization you work for.
What do you know?
It’s an honor to be asked, so this is good for your career. You love this topic and you really want to give this talk. The number of people who will be at the meeting (based on past meetings) will be between 700 and 800. Given the demographics, it’s likely that >95% of the people at the meeting will be vaccinated. You are vaccinated and boosted. The state they are holding the meeting in has a law prohibiting mask mandates and the organization has not put out any directives about masking or testing. The state they are holding the meeting in has an unvaccinated rate of … % and a COVID prevalence of … %. (Here’s where to look up these data.) There are people in your professional and personal life who are at high risk if you were to inadvertently bring COVID back to them.
What do you need to know?
Have the organizers addressed the issue of the mask mandate? Are the organizers going to require masks? Testing? Does your employer have rules or recommendations about travelling?
Step 2: Options
Go to the meeting
Don’t go to the meeting
The not so obvious
Go to the meeting
But just for the day you are presenting and don’t attend any other sessions
Go but avoid social gatherings and wear a N95 all the time
Don’t go to the meeting
Ask if they would consider a hybrid meeting so you can present virtually
Record your presentation so they can show it during your session
Step 3: Appeals
Rules/laws: The law in the state to not mandate masks should be addressed by the organizers of the meeting, but you can choose to wear a mask regardless. There aren’t any other obvious rules or laws that apply (unless your employer has restrictions on travel).
Consequences. If you go to the meeting you might contract COVID (possibly serious, only remotely irreversible, possible but not likely). You could bring it home to others (possibly serious, only remotely irreversible, unlikely). If you are sick there will be a burden placed on your work partners (could be serious, not that likely) If you don’t go to the meeting you might lose your status in the organization (possibly serious, only remotely irreversible)
What is the most virtuous thing to do? It may make the most sense to ask if the organizers will allow a hybrid approach so you can present virtually – or if they would let you record your presentation. But if those aren’t possible, you’ll need to decide if you are going or not. If you go to the meeting you are showing integrity (You said you would do it, so you are following through) and self-sacrifice (The organizers thought you had something important to say, so you are willing to take the risk). If you don’t go to the meeting you are showing legitimate self-interest (protecting yourself), compassion (for the family and friends you might inadvertently infect).You are also showing care and respect for your work partners, who would be burdened if you were to become ill.
First and second year medical students often are anxious about the “need” to publish but have trouble finding details about the process and goals of writing. Yes, it’s true. If you are going to be applying in a competitive specialty, you need to have at least one (but maybe a few more) publications. BUT (and this is really important, so please pay attention) there are two important things for you to know:
It’s called academic medicine because we are part of the academy! That means that we are trying to teach and change outcomes for the future. Don’t look on these papers as a “check box”. Find a meaningful question and learn from a mentor how to answer it. You will make a difference!
Secondly, you do NOT have to publish in the field you will ultimately choose. Publications are really a surrogate for being able to think, work in a team, and write. It’s showing that you can take a complex task and actually complete it. No one expects a first or second year student to know they want to be an expert in the pathology of Hodgkin’s disease! The key is to find a mentor who will teach you the process and show you how meaningful and fun it is to study something in depth and then share what you learned with others.
So how do you do this? It starts with a blank form:
So let’s break down the five steps from starting to publishing a clinical research project…. The times in parentheses are my estimates for how long this takes for a student who is on clinical rotations. If you are doing this full time as an month long research elective, it will take less time for each step. (But – note to self – you need to get the IRB request in 2 months before your research elective starts!)
Store your PDFs in Zotero – you can attach it as a file if it doesn’t automatically download. Don’t forget to add the Zotero plugin to Word if it doesn’t automatically install.
This last step is the key step (my opinion, others may have other strategies). My goal is to read each article ONCE. Therefore, I put EVERYTHING I think might be of interest from each article as I create my outline. It’s a lot easier to edit things out than add things in…
I start with an outline in Word that has headings something like this….
Natural history of the disease
So, I might read this paragraph in an article written by Smith et al in 2015 (I’m making this up – don’t quote anything written below!)
Pyloric stenosis was first described in 1886. Prior to the introduction of surgical treatment, the death rate was 50%. Surgery, which started in 1923 has now led to an almost 100% success rate with no mortality. The typical patient is male, and 4-6 weeks of age. They present with projectile, non-bilious vomiting and do not appear ill between episodes of vomiting.
So – using the outline in Word and Zotero I would do this…..
You then go on to subsequent articles and – even if they mention the same detail – you put it into the outline. For example, if you found 4 articles that said the typical age was 4-6 weeks, it would look like this: Typically 4-6 weeks (Smith, 2015) (Brown, 2011), (Jones, 2000) (Who, 1014)
Next, use your outline to start actually writing about the information you have gathered. As an example, switch to the “text” setting to change your note about age at presentation from “Typically 4-6 weeks (Smith, 2015) (Brown, 2011), (Jones, 2000) (Who, 1014)” to text that says “The average age at presentation is 4-6 weeks (Smith, 2015) (Brown, 2011), (Jones, 2000) (Who, 1014)”
The Institutional Review Board is responsible for protecting patients participating in research. Even if you are “only” reviewing charts, they must be protected with respect to confidentiality, etc. This is not usually true for case reports, but since many journals require IRB approval, you may have to submit it anyway and have the IRB letter that says it’s exempt.
It takes approximately 6-8 weeks to get the IRB approval after it is submitted. If they require modifications, it can take longer. You can’t (and shouldn’t) look at charts until you get this approval.
You must have IRB approval before you can submit the list of patients from the hospital with the disease you are studying. If they are treated by doctors other than the faculty you are working with, the IRB may ask you to send a letter via the hospital medical staff office to the other doctors giving them the option to exclude their patients if they want to. (They virtually never do, but this is a required step)
The “term paper” is just what is sounds like. Depending on the topic, it will be ~6-15 pages long with ~20-60 references. Here is where the outline and Zotero are so important.
Change the “view” in your outline to “draft”. The outline levels will be in Blue and will now be section headings. Everything that you wrote as text will be just that – text. You can write in this view or go back and forth between the draft and the outline if you want to rearrange sections.
All of the links to the references you put into Zotero using “Add/Edit Citation” will be in your draft. At this point, you click on “Add/Edit Bibliography”. It will prompt you to choose which journal you want (Yes! It knows the format of all the major journals!) and then will automatically create the bibliography. If you add new references in at the top of the manuscript, or change the order of the sections, you click this again, and it recreates the bibliography in the correct order.
As you are creating the outline, you are also designing the “data sheet” to retrieve from the charts the details you need to prove your hypothesis.
Writing a term paper is a great way to become an expert in the topic you are researching, but it also helps you later. The hardest part of any final paper to write is the introduction and conclusion – which you mostly do by writing the term paper!
Once you’ve got to this stage, you want to skim through the articles again to see if there are any “big picture” points you might have missed and then write the summary – i.e. the abstract.
It is ALWAYS better to write the abstract after the manuscript if you can. But – many times the deadline for the abstract will be used as the motivation/pressure to write the manuscript. Each attending will do this a little differently.
Use this section as a “journal” for your submission and for notes during meetings.
I look around the spaces I work, live, and worship in and I see so many people I love. I believe everyone is my neighbor, but I’m specifically talking about the people I know…the smiling clerk I always choose to check out my groceries, the guy who waves at me every morning when I drive into the garage, my family, the people who share my mission of healing children.
Only ~50% of the country is vaccinated and in some areas it’s only about ~30%. I know this means that some, maybe many, of the people I know and love aren’t vaccinated and, to be honest, it’s breaking my heart.
Because here’s the deal…
The Delta variant is dangerous. Every person who is infected with the Delta variant will infect 6-8 people on average (which is more infectious than Ebola or chicken pox)… Unless you are in a group of people like a break room, a church, a gym…. In which case the number will be much higher because of the closed space. Being vaccinated makes it MUCH less likely, but not impossible to infect people around you other because of “breakthrough infections.” These infections after vaccination are rare but expected – it doesn’t mean that the vaccine “didn’t work”.
Masks protect you (some) and everyone around you (a lot) which is why they are so important now – whether or not you are vaccinated.
But back to my friends and neighbors who aren’t vaccinated. The Delta variant is so infectious and spreading so fast that if you aren’t vaccinated, it’s not about IF you get infected, it’s about WHEN.
That’s why when I think about my beloved friends and neighbors I grieve because…
You will almost surely be infected with the Delta variant if you aren’t vaccinated.
You will go on to infect others around you, including people you love.
You will be sick (and probably really sick)… hopefully at home, but maybe not.
You may end up on a ventilator.
You may die.
And if you don’t die, you may be debilitated.
And it breaks my heart. Because these deaths are preventable. And even one of you dying or being debilitated is one too many.
I beg you…Get vaccinated. Wear a mask. #LoveYourNeighbor
A busy hospital service needs a way to keep up with the “to dos” of the day.
The junior residents and students responsible for these tasks need a way to know what they’ve done and what still needs to be done.
The senior residents and attendings need to keep track of the information and what is happening to guide and supervise the junior residents and students.
And all of this means keeping an accurate and up to date patient list. This can happen digitally in Epic, which is often what attendings use, but for most residents and students it means printing out the Epic list to keep in their pocket as they move through their day (and/or night).
p.s. If by chance you are still making your residents use Excel i.e. they have to physically create the patient list, shame on you! (Unless you don’t have Epic or another digital way to keep the list, in which case, I’m really sorry.)
And how do residents and students use the patient list?
Almost everyone draws little boxes for every detail they need to check off … and then puts a check in the box when it’s done.
Different colors for different tasks? Doodles? Notes during rounds or lectures? All of these and more, I’m sure.
“Running the list” means starting at the top of the list and discussing each patient sequentially, one at a time. We make sure to go over the plan for each patient, discuss what has changed, learn what has been “checked off”, and decide what needs to be added to the list.
This happens routinely at the beginning and end of the work day, and during handoffs. But, on a busy day, it may happen even more often.
So back to the original question
Although it sometimes actually feels like the intellectual equivalent of running, I suspect that the origin of “running the list” has to do with the idea of a “running list” i.e. a list that you add to as new things come up. But that’s just an educated guess, since I couldn’t find any actual data. If you have other thoughts, let me know!
Running the list is an important part of caring for patients, but it can also be a practice.
What if, like a competitive runner, you took a moment before you “run” the list to center yourself, take a few deep breaths and get ready to run?
What if you tried to visualize each person on the list as you review the day’s tasks to remember that these aren’t just tasks… they are human beings in your care?
What if we consistently made it a goal to teach just a little bit (or a lot, if the time permits) every time we run the list? (Would this be “walking” the list? 🙂 )
And at the end of the day, when you put your patient list in the shredder (don’t forget this important step! #HIPPA), what if you did it intentionally – to mark the end of the work day and the transition to not being in the hospital?
“I was mad at the ER, so I said, ‘Hope you have a quiet night!” as I walked out.”
There aren’t many people more scientific in their thinking or more evidence-based in their practice than physicians. And yet, like many of our sports heroes, many physicians are very superstitious. We know that saying the word “quiet” doesn’t actually change what happens. It’s such a prevalent superstition though, that there is one randomized trial that was designed to prove it! (Make that two randomized trials…)
Why are human beings superstitious? Particularly in the face of uncertainty (…so just how many patients will come into the ER tonight?) superstitions reduce stress by creating a sense of control. It has also been shown that superstitions increase self-efficacy, which in turn results in improved performance in sports and other tasks. Maybe this is why baseball players and other athletes are so superstitious?
My conclusion? I’m going to keep joining the chorus of groans from my team when the new medical student says [the-word-we-do-not-say] when we are on call. It makes us laugh, creates a sense of being in this together, and who knows… maybe our performance will be improved, too!
Every year about this time, I create a list of presents I think busy healers (and healers in training) would appreciate. I don’t have to tell you that this has been a year that for all of us, but especially for everyone in medicine, has brought a new level of stress and sadness. The healers need healing… and in that spirit, here are some ideas of what you can send your friends in medicine for Hanukkah, Kwanza, Christmas, the Winter Solstice… or to celebrate the end of 2020 and beginning of a new year of hope.
#10.White coat, jacket and/or scrub “bling”. Everyone who works in a hospital has a badge that must be worn all the time. And we all need pens (except for the attendings… we just “borrow” pens that students and residents keep in their pockets for us … just kidding … mostly). Here are some suggestions: Find a lanyard or badge holder from their favorite sports team or that will otherwise have meaning for them. Buy a box of cheap pens (that can be given away to needy attendings) + a great pen that will remind them of you every time they write with it. For white coats, find a meaningful or humorous pin that could be worn on other clothes as well.
#9 Happy Feet. Think about putting together a “happy feet” box – include things like warm slippers, good socks, a certificate for a pair of shoes to wear in the hospital, compression socks, toenail clippers, and any other foot care products that sounds right.
#8 Better sleep. Sleep can be hard if you have had a really hard stretch at work. It’s especially hard if you’ve worked all night and have to sleep during the day. You can put together a combination of gifts like new high-count sheets, eye covers and ear plugs for sleeping after a night shift, a certificate for a new mattress, a white noise machine or a weighted blanket.
#7 Work food. Busy students and residents frequently miss meals. Think about creating home made “snack packs” for the hospital by combining options like nuts, dried fruits, and high quality candy into small zip lock bags. Or buy healthy meal replacement bars in bulk. Make sure they are high quality, real food bars. My favorites are Kind bars but there are many other bars that are healthy and delicious.
#6 Gift cards. When you ask students and residents which gift cards would be most appreciated it’s pretty consistently these three: Amazon, Trader’s Joes, Whole Foods or other grocery stores, and Starbucks.
#5 Digital upgrades. A high-quality phone is a critically important tool in the hospital. Everyone in medicine spends a good part of the day texting each other, looking up patients on Haiku (the Epic phone app), checking UpToDate for the latest treatments, finding other medical information in many other places and – of course – staying in touch with our teams, friends and families. Up to date computers, iPads, and AirPods (or equivalent) are also great gift options for any student or resident.
#4 A cleaner house. Pre pandemic, I recommended someone to help clean as the number one gift for medical folks. But, even with the limitations imposed by COVID, there are still gifts that can help! Number one on this list would be a Roomba so they don’t have to vacuum.
#3 Healthy meals at home that don’t take time. The Instant Pot has been my top recommendation as a gift for students, residents and busy healers for several years. Another wonderful gift I’ve recommended before is How to Cook Everything Fast: A Better Way to Cook Great Food by Mark Bittman. This year, I would add a certificate to meal delivery plans. The one I use is Clean Creations (because I like to have vegetarian options), but many of my friends swear by Freshly. Every city has companies that are similar, so do some homework and you’ll find several to compare. If you are a good cook, you might consider creating your own “meal deliveryservice” for your loved one, especially if you live in the same city.
#2 Caffeine. This comes in different forms for different people, but unless they avoid caffeine for religious reasons, almost every healer and healer in training I know has a go to form of caffeine they love. For most people, it’s coffee. The number one gift on the list (my opinion) for coffee lovers is a Nespresso machine (and some pods to go with it). You can also get them a metal “pod” for their own coffee rather than the Nespresso pods which will save some money. There are other options for pod coffee machines, so you might want to read about them all before deciding. Having tried coffee from a variety of machines, I personal think Nespresso makes the best cup of coffee, but I am partial to espresso. Another great gift option for serious coffee drinkers is programmable coffeemaker so their coffee is ready when they get up at “dark thirty” to get to work. For tea drinkers, there are many options for teas, brewing systems, and pots. For all healers, regardless whether they are coffee or tea drinkers, a gift at the top of the list would have to be a Yeti or Contigo tumbler. These tumblers keep coffee or tea hot for hours… so your drink is still there and still hot when you get pulled away from that first sip.
#1 Money. Students and residents, with rare exceptions, don’t have money for special things. Some don’t have enough money after rent and loans for things most of us would consider essentials. Giving money may seem a bit impersonal, but you can make it personal with a letter, a card, or creative packaging.