We All Need a Compass

I was delighted to be asked to be the AOA visiting professor at the University of Miami Miller School of Medicine this week.  The following is the speech I gave at the induction banquet.  For those who are not in medicine, Alpha Omega Alpha is the “Phi Beta Kappa” of medical school, an honor society that recognizes students who are at the top of their class… but who have also demonstrated service, leadership and professionalism. 

 

What an honor that I have been asked to be here tonight for this celebration!  I am in the company of superstars and great friends, both new and old … what could be better?

I want to start by congratulating the junior AOA, resident and faculty inductees.  For the junior AOA inductees, you are clearly on a strong path to excellence which will serve you well.  Although I’m going to address my remarks to the graduating seniors, please know that I haven’t forgotten you or what it took for you to be here tonight.  For the resident and faculty inductees, you have been singled out for this very particular honor because you are amazing clinicians, educators and role models.  Thank you for what you do.

I thought I’d start with a short description of what it means to be inducted into AOA from the AOA website.

“Election to Alpha Omega Alpha is an honor signifying a lasting commitment to scholarship, leadership, professionalism, and service. A lifelong honor, membership in the society confers recognition for a physician’s dedication to the profession and art of healing.”

Induction into AOA is a major milestone in your career and, based on your predecessors in the organization, it also represents the beginning of a remarkable journey.  It’s a journey that you won’t take alone.  If history is a guide, you represent the future leaders of medicine, which means you’ll be guiding others on this journey as well.

That’s the reason I decided I should talk about how to use a compass.

 

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I suspect that you have all used a compass before but, like me, you probably haven’t given it much thought.  A traditional compass works by aligning a needle to the magnetic pulls of the north and south poles.  Although we really could use either north or south as a reference point, by convention we use north. I’m not going to get into the differences between true north and magnetic north*… suffice it to say that because a compass lets us know where north is, we can calculate the difference between “true north” and where we are heading, which in nautical terms, is called our “absolute bearing”.

So where am I going with this?  Why is it important to have a point of reference, a “true north”, as you start your journey through residency into the practice of medicine?

I know you’ve already been on services where the focus seemed to be more on checking the boxes on the scut list than on caring for the patients… and you had the feeling that there was something missing.

That’s why you need a “true north”.

You’ve also been on committees or in organizations that seemed to worry more about policies and procedures than how to use those policies and procedures for the better good.

That’s why you need a “true north.”

And I know that you have experienced days where you manifested one or more of the three cardinal symptoms of burnout, days when you lost enthusiasm for your work, felt that patients were objects rather than people and/or decided everyone around you could do a better job than you could.

That’s why you need a “true north”.

Unless you know where your “true north” is, you can’t navigate… you can’t make the adjustments that keep you on course.

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The single most important piece of advice I can give you as you start on this journey is to make sure you know where “true north” is for you.  As each of you define your own personal “true north”, you will share things in common.  For example, loving your family and friends, being kind, and trying to make a difference.  But even though there will be common themes, “true north” will be a little different for each of you.  This is not as abstract a concept as you might think. It is not only possible to articulate your goals, what gives you meaning and how you define your own integrity, it’s important to do so. And, yes, I mean write them down, think about them, and revise them when necessary.  When you hit the inevitable days of stormy weather, having a compass that it true is critically important.

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In reading about compasses, I also learned that the traditional compass has to be held level to work.  I learned that “when the compass is held level, the needle turns until, after a few seconds to allow oscillation to die out, it settles into its equilibrium orientation.”

What a great image.  You have to be still to let the compass equilibrate.  You have to be mindful to look at the needle to calculate your absolute bearing.  And then you have to take that information and apply it to correct your course.  And to do so, you have to hold the compass level, which I think is a great metaphor for taking care of yourself – physically, emotionally and spiritually.

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There is not a lot in the day to day life of an intern, resident or practicing physician that teaches us the skill of focusing on that still point, on getting our bearings to make sure we don’t veer off course.

It’s not a trivial problem.  Veering off course can result in doing something we don’t want to do or, more importantly, becoming someone we don’t want to be.  More importantly for those of you just starting on this journey, a small error in navigation at the beginning of a journey results in a very large error when you arrive.  That’s why, as you start this journey, it’s so important to know what “true north” is for you.

As you articulate what your “true north” is, I would also urge you to translate it into something that is easy to remember for those times that you are making a decision in a difficult moment.   For me, my “true north” as a physician has been distilled into three rules that I try to follow and that I teach my trainees.

Rule 1:  Do what’s right for the patient.

Rule 2:  Look cool doing it.

Rule 3:  Don’t hurt anything that has a name.

Let me expand just a little…

Rule 1 means always do what’s right for the patient.  Even if you are tired, even if others disagree, even if you don’t get paid, even if it’s not technically “your” patient – do what’s right.  It also means developing an life-long method to deliberately read and study so you know the right thing to do.  And it means doing all of this with compassion and integrity.

Rule 2, “Look cool doing it”, means practicing your art until you look cool.  If you are surgeon, make sure your movements look like Tai Chi and that you have no wasted motion.  If you are a pathologist, learn all the variations on the themes that cells can create. No matter what your specialty, read about each of your patients, prepare for all cases, procedures and conferences deliberately and diligently. “Look cool doing it” also means don’t lose your cool.  Be professional, which at its core is just another way of saying kindness and integrity matter.

Rule 3, “Don’t hurt anything that has a name”, certainly means don’t cut the ureter if you are doing a colectomy, but it means more than that because…

You have a name.

Your significant other has a name.

Your institution, your friends, your family all have names.

You are about to embark on the amazing and challenging journey of residency… I know you have a sense of trepidation and also a sense of incredible excitement.  Everyone in this room who has been there remembers and, to be honest, is probably a little jealous. What an amazing time to start a career in medicine.

Congratulations on all you have accomplished so far. I wish you smooth sailing and a compass that is true.

 

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*Because I am using “true north” as a metaphor, the scientists will have to forgive me.  There is a difference between “true north”, which is the actual north pole and “magnetic north” which is what a compass shows.  Here’s a great link that explains this further:  Magnetic North vs Geographic (True) North Pole

 

 

 

Top 10 Holiday Gifts for Physicians and Physicians in Training

The holiday season is rapidly approaching.   Here’s my top ten gifts for medical students, residents and physicians…. or any busy friend!

  1. Mark Bittman’s new book How To Cook Everything Fast.

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This is an amazing cookbook and it is perfect for busy people. The recipes are interesting, delicious and healthy. The instructions are easy for a novice without being simplistic and the layout of the book in innovative and makes it really easy to use.

 

  1. An electric pressure cooker.

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Slow cookers are often suggested for medical students and residents but I don’t think they are as good as a pressure cooker.   You have to be there when slow cookers are (slowly) cooking, which is usually your rare day off. Also, it’s hard to cook vegetables in a slow cooker. Pressure cookers on the other hand cook broccoli in 2 minutes (perfectly!).  I’ve been told that the electric pressure cookers take a little longer to come up to pressure, but it seems a small downside for a device that also lets you slow cook, steam, sauté, and cook rice.

 

  1. Coffee or Tea

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There are several options to consider if they are a serious coffee or tea drinker. A Starbucks or Teavana gift card in a cute “medical” coffee mug? A Starbucks Verismo coffee brewer? Nespresso? Keurig?

 

  1. A FitBit

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Anyone in medicine loves gadgets and loves data. The fitbit has become a socially acceptable piece of “jewelry” in the hospital and it unquestionably changes behavior to increase activity. Having washed three of the “clip on” Fitbits with my scrubs, I would recommend one of the wristband Fitbits!

 

  1. A maid or housecleaning service

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Doing housework has to be on everyone’s lowest list of fun things to do on your day off, but it’s especially true for people who are studying extensively or taking call in the hospital. My parents helped finance someone to come occasionally to help clean my apartment when I was an intern. It was without a doubt the best present I’ve ever received.

 

  1. Anything that helps make it easy to get more exercise

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Another great gift is anything that will promote more exercise… a bicycle to commute to school or work? Yoga classes? Spin classes? A gift certificate for new running shoes? Resistance bands for the call room? A membership to a YMCA or a gym close to where they live? Certificates for post workout massages?

 

  1. “Date night” packages

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Whether they are single or have a significant other, being able to socialize is an important part of stress reduction for busy people.   Create combinations of gift cards to movie theaters and restaurants to support “date nights”. If they love art, music, or sports think of season tickets (or ticket packages) to museums, music venues or professional sport teams.

 

  1. An “over the top” alarm clock

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It’s not easy getting up at “dark thirty” to make it to rounds, but being on time is important.   The snooze button is not a good idea… but it’s so easy to hit. This alarm clock is my personal favorite to make sure you get out of bed. After a few hits of the snooze button, it rolls off the table and around the room until you turn it off!

 

  1. Great books by, for and about doctors.  

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If they are a serious reader, think about a Kindle (or other eReader). The Kindle paperwhite is small, lightweight, back lit and has a great battery life – which makes it great for the occasional times on call that you can find 30 minutes to escape into a good book. You can also read it outside in bright sunlight (unlike tablets like the iPad) On my list of great reads for doctors (in no particular order)…

Cutting for Stone by Abrahan Verghese

How Doctors Think by Jerome Groopman

House of God by Samuel Shem

The Immortal Life of Henrietta Lacks by Rebecca Skloot

The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukheries

Being Mortal: Medicine and What Matters in the End by Atul Guwande

William Osler: A Life in Medicine by Michael Bliss

The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures by Anne Fadiman

 

  1. The always appropriate gift of money

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If you are going to give gift certificates or money,  “package” it with some humor (in a pill bottle with a “prescription”) or a context (this is to help you buy good food for times you are too busy).

Please let me know (comment or email) anything else to add to this list!  Happy Holidays to all!

 

 

This Year’s @drmlb’s Top 10 Gifts for Medical Students, Residents and Busy Docs.

This time of year, family and friends of docs and/or docs in training are looking for the last minute holiday gifts (if you are trying to have them shipped) or planning the trip to the store(s) for gifts.

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The one thing any busy person doesn’t have enough of is time.  If you think about it in that context, you can find presents to support interests, fitness, studying (or just having fun) in a thoughtful way.

1. Someone to help clean their home.  It is the most amazing present to come one once a week (or even once a month) to a house that has been cleaned by someone else.  If there are family members who are willing (and it’s appropriate) you can put together a gift of cleaning supplies with a certificate for monthly housecleaning.  If not, word of mouth to find the best person is usually the best way, and will often help you find someone who also does laundry and ironing.  (a true gift!).   There are professional services in every city as well that can be found with an easy internet search.
2. Something to help integrate fitness into their every day activities.  If they don’t have a good bike to commute to school or the hospital (and this is something they would like) this is a great present.  Don’t forget the helmet, reflective vest and very bright lights as part of the package!
3. A fast computer.  If they have the same computer they had in college and you are able to do this for them, the time they will save in uploads will be very appreciated!
4. A smart phone or mini iPad (especially the new iPad air).  Like the computer, if the phone they have is more than 3-4 years old, the upgrade will be much appreciated.  The mini iPad (instead of the regular size) fits in a white coat pocket, which is why it’s ideal for anyone who wears a white coat.  If they have an iPad, think about some of the more expensive medical apps. (or a certificate for the App store
5. Kitchen appliances to save time (and promote healthy eating).  My favorites on this list would include a rice maker (which can also be used to steam meat and vegetables), a pressure cooker a slow cooker or the Krups multi-cooker.  A blender is always a good gift (to make smoothies and soups).  If you are feeling particularly generous, a VitaMix instead of a blender is much more versatile (and makes much better smoothies!).
6. Prepared meals. If you have family who love to cook, you can make a “certificate” for homemade food in freezable portions.  If you can afford it, there are personal chefs who do the same thing.  You can also give them a gift certificate for a grocery store like Whole Foods that has healthy prepared food or companies that deliver healthy meals (In Houston, it’s companies like MyFitFoods – but this varies from city to city).
7. Fitness equipment for home.  For medical students who are spending a lot of time studying think about a FitDesk, FitBike or a treadmill desk.  The standard stationary bikes, treadmills, etc are another option, but they are expensive and you have to really know that they are preferred over going to the gym (see #8).  A less expensive but very effective gift would be a “fitness care package” with resistance bands, FitDeck cards, a gift certificate for running shoes, and other small less expensive gifts.

8. A membership in a local gym. You can also consider a certificate for group classes in spinning, yoga, or whatever they enjoy.
9. Time with family and friends.  Think about a “certificate” for time together – maybe with restaurant gift cards or movie gift cards attached.  A “certificate” for a monthly home cooked meal?  If you aren’t in the same town, think about how to make it easy for them to spend time with their friends.  If you know their favorite restaurant or hangout, see if you can get a gift certificate.  If not, go for tickets to the local theater, one of the movie chains (find out which one is closest to where they live), or their favorite restaurant chain. If they have children, babysitting is a wonderful gift.
10. Whatever you can think of that makes gives them more time and/or will support them during times of stressful and busy work!

 

 HAPPY HOLIDAYS TO ALL!!!PEACE_ON_EARTH

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Last year’s suggestions on wellnessrounds.org

Residency Interviews Part 1: Your Suitcase

It may seem kind of strange to write a post on just suitcases, but bear with me.  For many medical students, the trips they will make for residency interviews will be their first real “professional” travel.  If you haven’t travelled a lot, you don’t know everything that can go wrong…. So here are some rules to help you.

p.s. I’m doing this first in a series of blog posts on how to interview in case anyone needs to drop a hint that they need a new suitcase (and possibly new clothes) as an early holiday present.

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Rule 1:  Try not to check your bags

Make it a goal that no matter where you go (or for how long ) you will always have what you need in a carry on suitcase. I went to Russia last year for two weeks – in the winter – with two carry-ons. Once you practice this, it’s not hard.

Why bother? What could go wrong?  Just ask around.  It won’t take long until you hear the story of someone who to ended up at an interview in New York when their bag was in Nebraska.  Which brings me to rule 2.

Rule 2:  Assume you will be sitting next to the chairman of the department on the plane.

You don’t have to wear “interview clothes” on the plane but don’t have on anything that you would regret.  It is really remarkable how many times you will end up sitting next to someone you will see the next day in your interview…. or someone who lives next door to your future program director.

Rule 3:  Have clothes in your small carry on bag that you could use in a pinch to interview.    Ditto your toothbrush, razor, etc.

Even when you plan to carry on your suitcase, there are times you get on last and there is no room for your bag.  Although it’s unlikely, it’s not impossible they will mess up and your bag isn’t there when you arrive.  Think ahead.  Pack your shirt, tie (or female equivalent) in a small travel “folder”.  Put it in the outside pocket of your suitcase so you can grab it if your bag can’t be checked.

Rule 4:  Make a travel checklist and go over it before you leave to make sure you have everything. 

This is something you learn the first time you get to a meeting and you don’t have a jacket to put on in the cold room.  I’ve put the outline of the one I use at the bottom of this post for you to modify for your use.

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The next thing to do is make sure your suitcase is appropriate.  Residency interviews are often a catalyst for buying a new suitcase.  This is a good time to ask for an early holiday present if you need some help to buy a good one.

Options for suitcases

The regulations for suitcases vary a little by airline, but the take home message is get a suitcase that is 22 inches tall and not too wide if you plan to carry it on the plane.   There are many other options, but the two companies that have really focused on good quality, lightweight carry ons are TravelPro and Eagle Creek.  TravelPro suitcases are used by pilots and flight attendants, which tells you a lot.  I personally like Eagle Creek because of their packing system.  There are other companies, too, so look around.

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How to pack without wrinkles

One way is the Eagle Creek system, but there are others like wrapping your clothes around a bag with smaller items, rolling your clothes and using plastic covers, and packing little items around the bigger ones to avoid movement.

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How to get more things in the suitcase

Think of packing like a puzzle.  Put all your clothes on the bed to start with, then fill in spaces.  For example, pack your socks in your shoes.  Roll up workout clothes to pack in the edges.  But – unless you want wrinkles – don’t overpack.

Here’s a great video on how to pack more clothes with less wrinkles – seriously, watch this one.

Your “other” carry on bag

You’ll need to carry something with you when you interview for your papers and to collect the things they give you.  This is a good time to carry something a little more professional than a back-pack.  At a minimum, have a portfolio or a nice, small briefcase.

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For the plane, choose a carry on bag to carry your folio, the “emergency” interview clothes, whatever you are reading, your music, etc.    These carry on bags, which often match the luggage, are designed to have as much room as possible but still fit under the seat.

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Travel Checklist (as promised)

Interview/meeting clothes

Suits/business wear x ___ days

Undergarments

Sweater/fleece (cold rooms?)

Heavy coat, scarf, gloves, hat?

Small purse/briefcase

Might need for some locations

? formal wear

? rain wear

? umbrella

? Passport

? Sunglasses

? cap

Toiletries

Toothbrush/toothpaste

Deodorant

Hair product

Hair brush

Razor etc

Sun screen?

? Extra glasses

? contacts

Workout

Gym wear

? Swimsuit/goggles

? exercise bands

Miscellaneous electronics

Camera/batteries

Computer/cord/plane power cord

Thumbdrive

Kindle/cord

iPhone/charger

iPod/earbuds

iPad/charger

(Rental car? – garmin, phone charger)

For the plane

water bottle

neck pillow

snacks

How to Succeed in Residency: Studying

Today is the “official” first day of residency.  If you are one of the ~16, 000 new interns starting today I have good news and bad news.  The bad news is that you are already behind in terms of what you need to know.  The good news is that you can come up with a plan that will make a big difference.  If you are a PGY2 or greater, this is a great time to reapply yourself to your studies – even if you let it slide last year.

 “The best time to plant a tree is 20 years ago.  The second best time is today.”  Chinese Proverb

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As an intern or resident, you learn your specialty from a variety of sources.  Each of them is important.  Some of your studying will be just like medical school with your gluteus maximus in a chair (or feet on a treadmill or ischial tuberosities on a bike or an exercise ball) reading a textbook.  But the rest of what you learn is absorbed as you make rounds, attend conferences and take care of patients.

The challenge is organizing what you learn.

Sometime this week you will do your first central line, or see a case of bile gastritis, or attend a conference where they discuss a patient with a rare fungal infection.  The amount of new information you will learn in these first few months will truly be astounding.  But how is what you learned going to be available to you 8 months from now when you see the second patient with the same unusual infection?  How are you going to be able to review what you have learned when January rolls around and its time for your in-training exam?  At the end of your residency, will you be ready to take the boards?

There is no right or wrong way to create a system for studying clinical medicine, but there are a few principles that will help.

1.  Record what you learn as you learn it. 

There’s no way around it.  If you really want to learn clinical medicine, you have to make notes. Go to work every day with blank 3×5 cards in your pocket.  When you learn something on rounds, write it down on a card.  When you look up something related to a new patient you are working up, write it down on a card.  Make it brief, legible and to the point.  If there are “hooks” (i.e. the patient had a tattoo of Spiderman on his face) put it on the card.  It’s how our brains remember.

One of the consequences of duty hour regulations is that any given resident today will see fewer patients than residents did 10 years ago.  I’m not at all against duty hour regulations (although I do think there might be some better ways to organize time for learning), but you have to take this reality into account.  You can never completely replace seeing patients, but being comprehensive in your studying will help.  For example, let’s say you admit a patient with dyspnea and an arrhythmia who turns out to have a Morgagni hernia.  This is rare, and it’s not likely you’ll see multiple cases during your training.  You make a card on how the patient presented and another card on what the treatment was.  But then you go to the literature and find a case of a woman with a Morgagni hernia who presented with a complete right middle lobe compression and another case of an octogenarian who presented with life threatening vomiting.  You have now created “virtual” patients in your mind that add to your pattern recognition. Most importantly, you do it at the time it means something.

One other important thing – don’t ever use scratch paper with plans to copy the notes later.  It just won’t happen.  Make the notes once, no matter how bad they look!

Alternates to the 3×5 card system

  1. Use 8×11 pieces of paper to record what you learn.   Fold them up in your white coat pocket.  Scan them into your computer or put them in a binder.  Don’t put more than one topic per page, though, or you will have trouble organizing them.
  2. Use an iPad or other electronic device. We are on the verge of having facile enough (and small enough) handheld digital devices to do this just as well (or better) than my 3×5 card system.  The problem is being able to make your notes on the spot because the device isn’t with you.  It never works to plan to make the notes later and, as I said above, it never works to copy notes.  There are just too many things you’ll be writing down to make this work.  If you figure out a good way to use an iPad or other device, please let me know! (use the comments below).
  3. Use the computer.  We live on computers.  There’s no reason you couldn’t type 3 lines of what you learned and email it to yourself or save it directly to the cloud.  The advantage of cloud storage is that all your notes are available all the time and are searchable.  DropBox is not HIPAA compliant!  Don’t put any patient identifiers in the notes if you choose to use the cloud.
  4. Look for software, devices or storage that makes sense for you.  Here’s a place to start.

2.  Be comprehensive. 

Get a major textbook in your field and write down every topic it covers.  You’ll see patients with a majority of them in most training programs.  When you see the patient is the time to read the textbook.  Make it your goal to cover the textbook in a year.  Come up with a system to monitor your progress.

When you are sitting/walking/cycling as your study the textbook, make cards to review later.  These can be a little more complete, a little fancier and have more detail.  The idea here is to read each chapter once and make notes that are complete enough that you never have to go back.

3.  Stay curious.

Being excited by what you are learning will always make it easier.   “Set up habits that encourage, and don’t squash, your natural curiosity: Look up answers to your questions, not just subjects you are instructed to read about.”

 “The very first step towards success in any occupation is to become interested in it.” William Osler

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3.  Repeat. Repeat. Repeat.

Learning is iterative.  You don’t really know something until you have studied it multiple times over a period of a month or two.   Don’t make your notes, file them away and pull them out the week before the in-training exam.  Sit down once a week and just glance through them all.  Develop a system that lets you review them 24-48 hours after you make the notes, a week later, a month later, and 3 months later.

 

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“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler

The Best of Wellness Rounds 2011

HAPPY NEW YEAR TO EVERYONE!

Advice for interns

Why I hardly ever drink diet drinks

How to choose your specialty

What to do on your day off

Studying basic sciences – strategies for success

Studying clinical medicine

Getting (and staying) motivated to exercise

How to succeed on clinical rotations

Gifts for medical students and residents

Why I’m spending more time on Twitter

How not to have sore feet after a day in the hospital

What To Do This Summer

This week approximately 16,000 US medical students are going to receive their diplomas and become physicians. There are also about 16,000 college graduates who will start medical school later this summer or early in the fall.  Congratulations to you all!

Nearly all of you have a well-deserved month (or two)  to rest and get ready for the next step in your training.  So, I thought it might be helpful to pass on a few words of advice on how to spend your time this summer.

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Do NOT study!

 

  • If you are starting your residency and you think it might help relieve your (normal) anxiety, here is what to do:  Buy one of the major textbooks and use it to get excited about what you are going to learn.   If you want to, plan how you are going to study for the year.   Skim the book if you really have to do something to feel less anxious, but don’t spend hours studying.
  • If you are getting ready to start medical school – step away from the books!  Seriously, there is nothing you can do that will make it any easier, so just enjoy your time off!

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Take a vacation (or two or three…)

  • Visit family and friends – take a road trip and connect with people you haven’t seen in a while
  • Hang out on a beach, go for some great hikes, read some great novels
  • Sleep late, eat well, and just rest

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Develop (or strengthen) an exercise habit

  • Use this summer to develop a daily exercise routine that you can take into your new (and crazy) schedule.  Overall, your goal for the summer should be to develop a balanced exercise program (cardio, strength training and flexibility).  If you’ve never done any strength training, hire a trainer and learn about it.  Your goal should be at least 30 minutes of cardio 4-5 times/week, 2-3 strength training sessions/week and stretching every day. If you develop a balanced exercise routine this summer, it will be much, much easier to continue this once you start medical school or your internship. Commit to doing at least 30 minutes of exercise a day this summer.
  • Running is one of the best (and most convenient) cardio exercises for medical students and residents (because it’s cheap, efficient and effective)  Use this summer to become a runner. If you hate running, find another good cardio exercise habit to develop instead – but pick one!
  • If you don’t own a bicycle, think about getting one that you can use to commute to school or the hospital.

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If you don’t know how to cook, learn.