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.
Twitter has become a wonderful way for me to send out a variety of ideas and links that I think are helpful (and/or interesting). Here are this week’s highlights! If you are new to Twitter RT means Retweet (just “forwarding” it as is) and MT means Modified Tweet (“forwarding” it with a comment).
- Damned if you do, damned if you don’t – the ethical dilemma of #resident duty hrs bit.ly/r3KO1C #meded @drmlb
- “This is definitely a 15 minute video every medical student should see.” The art of the physical exam bit.ly/nnmaTN @drmlb
- The value of narrative in both medical non-fiction and fiction RT @hastingscenter Hastings Center bit.ly/rnx8Zs
- Baked oatmeal. Make it on the weekend, have it for breakfast all week – great idea for #medstudents #residents bit.ly/n6k3Z1 @drmlb
- Comments one makes to colleagues: as important as the interview. Professionalism = doing the right thing when no one’s watching. RT @MedPedsDoctor
- #Surgeon study finds limits on training hours may impede medical performance fxn.ws/p66MoS RT @MedEdAMA
- Beginner’s mind in medicine. How to keep what we do exciting! MT@KevinMD bit.ly/qle7SJ
- One flight of stairs = 16 calories burned. One day on call = ?10 flights ?20 ?30)..it adds up! @drmlb
- “…small things often adds up to produce a far greater impact than any of us realize.” Surgery through different eyes bit.ly/q5XUkh @drmlb
- “..those of us who spend our emotions at work are not the kind to view our work as “just a job.” MT@Kevin MD bit.ly/pRAbmm @drmlb
I became aware of this book last week through one of the anesthesia residents at work (whose chairman made this book required reading for all residents in his department). Dr. Gautam is a psychiatrist who has specialized in caring for physicians and is an expert in physician wellness. She uses training for an Ironman triathalon as an analogy. Physicians have to “train” for different roles (personal and professional) if we want to prevent burnout. She proposes a training program that helps keep balance in the complicated life of a doctor. The book primarily addresses physicians already in practice, but the information is very applicable to trainees, as well.
Here’s her website if you are interested: http://www.drgautam.com/gautam/books.htm
People who are ill or hurting often turn to their religious roots for solace. The mind and body connection is a powerful one, and one that can contribute to good patient care. Spirituality in medicine can take an overtly religious tone, but only if both the physician and patient are completely comfortable. No matter what your religious background, you will care for patients whose belief system is different from your own. The true root of spirituality in medicine is compassion. Regardless of your religious background and your personal beliefs you can cultivate a philosophy of compassion. Both you and the patients you care for will do better because of it.
The workday can be onerous and fatigue can make you lose perspective. It is important to find something greater than you and spend some time there everyday. The most efficient method is to look inside of yourself by just sitting. Learn to just sit. It is harder than it sounds, but very powerful when achieved. Slow your breathing, close your eyes and let the thoughts go. Concentrate on your breathing and relax all your muscles. Don’t fidget, don’t move. When the thoughts start running (and they will), just acknowledge them and let them go. Try to get to a moment (and that it all it will usually be) when your mind is silent and your body relaxed. This is the moment to listen. Being able to quiet yourself this way is very conducive to allowing your mind to work on the “big picture”. If you spend even 10 minutes everyday in this kind of meditation, you will be surprised at how some of the things that are worrying you become “solved”.
Work at finding beautiful places where you can sit for a minute or walk. Nature is one of the most powerful spiritual experiences. If you have a favorite place to hike or be outside, take some pictures and blow them up for your house or call room. Put beautiful plants in your house and then take care of them. (Dead plants are a bad way to cultivate spirtituality…) Watch for the surprising moments of beauty in a day and notice them. Look for the flower blooming outside a patient’s room, the proud look of a father watching his two-year-old totter into the hospital, a new painting on the wall.
Cultivate a sense of wonder. Have you ever seen anything more incredible than a beating heart in a surgeon’s hand? Allow yourself a moment to be amazed in the middle of the day. People have incredible resilience at times – notice it and appreciate it.