He for She, We for Us

Ever since my presentation to the American College of Surgeons earlier this month on personal resilience in a medical career, I cannot shake the feeling that we need to do more of this work. Physicians from different fields need to talk more to one another, share experiences, and reconnect.  We also need to include other members of the care team as equals, and let go the hierarchical thinking that has far outlived its usefulness.

I do not suggest that physicians, nurses, therapists, pharmacists and others should play interchangeable roles in the care of patients. Rather, similar to the central tenet of gender equality, the unique contributions of each team member need to be respected equally for their own merits and importance.  As a primary care internist, I must admit that I have seen my professional world through a rather narrow lens until now.  I confess that I live at Stage 3, according to David Logan and colleagues’ definition of Tribal Leadership and culture.  The mantra for this stage of tribal culture, according to Logan et al, is “I’m great, and you’re not.”  Or in my words, “I’m great; you suck.”

“I’m a primary care doctor and I am awesome. I am the true caregiver.  I sit with my patients through their hardest life trials, and I know them better than anyone.  I am on the front line, I deal with everything!  And yet, nobody values me because ‘all’ I do is sit around and think.  My work generates only enough money to keep the lights on (what is up with that, anyway?); it’s the surgeons and interventionalists who bring in the big bucks—they are the darlings of the hospital, even though they don’t really know my patients as people…”  It’s a bizarre mixture of pride and whining, and any person or group can manifest it.

Earlier this fall, Joy Behar of TV’s “The View” made an offhand comment about Miss Colorado, Kelley Johnson, a nurse, wearing ‘a doctor’s stethoscope,’ during her monologue at the Miss America pageant.  We all watched as the media shredded the show and its hosts for apparently degrading nurses.  What distressed me most was the nurses vs. doctors war that ensued on social media.  Nurses started posting how they, not doctors, are who really care for patients and save lives.  Doctors, mostly privately, fumed at the grandiosity and perceived arrogance of these posts.  It all boiled down to, “We’re great, they suck.  We’re more important, look at us, not them.”  The whole situation only served to further fracture an already cracked relationship between doctors and nurses, all because of a few mindless words.

It’s worth considering for a moment, though. Why would nurses get so instantly and violently offended by what was obviously an unscripted, ignorant comment by a daytime talk show host?  It cannot be the first time one of them has said something thoughtlessly.  What makes any of us react in rage to someone’s unintentional words?  It’s usually when the words chafe a raw emotional nerve.  “A doctor’s stethoscope.”   The implicit accusation here is that nurses are not worthy of using doctors’ instruments.   And it triggered such ferocious wrath because so many nurses feel that they are treated this way, that they are seen as inferior, subordinate, unworthy.  Internists feel it as compared to surgeons.  None would likely ever admit to feeling this way, consciously, at least.  But if we are honest with ourselves, we know that we all have that secret gremlin deep inside, who continually questions, no matter how outwardly successful or inwardly confident we may be, whether we are truly worthy to be here.  And when someone speaks directly to it, like Joy Behar did, watch out, because that little gremlin will rage, Incredible Hulk-style.

I see so many similarities to the gender debate here. As women, in our conscious minds, we know our worth and our contribution.  We know we have an equal right to our roles in civilization.  And, at this point in our collective human history, we feel the need to defend those roles, to fight for their visibility and validity.  More and more people now recognize that women need men to speak up for gender equality, that it’s not ‘just a women’s issue,’ but rather a human issue, and that all of us will live better, more wholly, when all of us are treated with equal respect and opportunity.  The UN’s He for She initiative embodies this ideal.

It’s no different in medicine. At this point in our collective professional history, physician-nurse and other hierarchies still define many of our relationships and operational structures.  It’s not all bad, and we have made great progress toward interdisciplinary team care.  But the stethoscope firestorm shows that we still have a long way to go.  At the CENTILE conference I attended last week, I hate to admit that I was a little surprised and incredulous to see inspiring and groundbreaking research presented by nurses.  I have always thought of myself as having the utmost respect for nurses—my mom, my hero, is a nurse.  The ICU and inpatient nurses saved me time and again during my intern year, when I had no idea what I was doing.  And I depended on them to watch over my patients when I became an attending.  But I still harbored an insidious bias that nurses are not scholarly, that they do not (or cannot?) participate in the ‘higher’ academic pursuits of medicine.  I stand profoundly humbled, and I am grateful.  From now on I will advocate for nurses to participate in academic medicine’s highest activities, seek their contributions in the literature, and  voice my support out loud for their important roles in our healthcare system.

We need more conferences like this, more forums in which to share openly all of our strengths and accomplishments. We need to Dream Big Together, to stop comparing and competing, and get in the mud together, to cultivate this vast garden of health and well-being for all.  I’ll bring my shovel, you bring your hose, someone else has seeds, another, the soil, and still others, the fertilizer and everything else we will need for the garden to flourish.  We all matter, and we all have a unique role to play.  Nobody is more important than anyone else, and nobody can do it alone.

We need to take turns leading and following. That is how a cooperative tribe works best.  It’s exhausting work, challenging social norms and moving a culture upward.  And we simply have to; it’s the right thing to do.

Hippie Zealout Conference High! Notes from CENTILE 2015

Hello again, friends, I have missed you!  It’s been an exciting and exhausting month of travel, nature, speaking, and learning.  My brain and heart are both so full I can hardly stand it, and all I want to do is write and talk about it!  Last week I attended yet another phenomenal meeting!  I feel another quantum leap coming on, both professionally and personally.  Below is the spontaneous post I wrote over lunch on Tuesday, and I wish I had published at the time.  I would have made my own deadline and… well whatever, it’s all about learning to put myself out there with less fear and judgment.  *sigh*

Now I have some time to synthesize and process…  Here’s hoping I can articulate and share effectively! 🙂  Thank you for reading, and please share your thoughts! –Cathy


Tuesday, October 20, 2015

Hello from Washington, DC! I submit this report from Day 2 of the CENTILE Conference, 2015, the International Conference to Promote Resilience, Empathy, and Well-Being in Health Care Professions.  I am in symposium heaven—it’s a veritable love fest of like-minded and like-souled physicians, nurses, educators, scientists and others, all here to share what we’re doing to make medical practice and practitioners healthier!

In the spirit of sharing and collaboration, I present in this post the highlights of the conference so far, and invite you all to reply and share how they resonate with you. Let’s explore how we can make not only medicine more humane, but life on Earth, and all of our relationships, too!

Caveat: My own thoughts will appear in [brackets]. The other ideas come from my handwritten notes, and I make no claims of content accuracy.  They are what resonate with me personally, experienced through my existing filters…  I hope they move you, as well.

  • ‘Burnout’ may be an obsolete term, fixing our gaze on what’s wrong. It may benefit us all more, rather, to shift our attention to wellness, in all its forms and layers. [“Energy flows where attention goes.”]
  • Six areas of job-person fit or mismatch:
    • Workload
    • Control (choice, discretion, voice)
    • Reward (compensation, recognition, acknowledgement –[“I see you.”])
    • Community (workplace RELATIONSHIPS!!!)
    • Fairness (promotions, etc. [!gender bias])
    • Values ([Your WHY—does it align with the organization? Does the organization walk its talk? Does it allow or hinder you to walk yours?])
  • There are mountains of burnout data, and only molehills for interventions and their outcomes—now we know what to study!
  • Individual strategies are not enough, the system/context also needs to change in order for providers to be well and do their best work—the data is sparse, but that which exists suggests that this is the more effective approach—we need BOTH.
  • Workplace civility: Our words and body language matter, more than we know! When we act meanly or kindly, it does not just affect the other person, it affects everybody. Thus we can choose, in everything we say and do, to contribute to a more loving or a more toxic work environment.
  • We need to change our culture. This will not happen overnight—”there is no antibiotic!” We need to think of it more as sustained lifestyle change—[diet and] exercise!
  • There is now a growing consortium of pediatrics residencies, all collecting data on baseline wellness, innovating and implementing strategies for improvement, and reporting outcomes! Wooooooooo hooooooooooo!!
  • More and more medical schools are changing the traditional teaching models and including resilience training, with amazing results. At St. Louis University School of medicine, by making the first two years pass/fail, decreasing curriculum time by 10%, and offering longitudinal electives, the depression rates among first and second year medical students dropped from 25-35% to 8-21%, and for anxiety from 54-61% to 14-47%, respectively. Holy cow!
  • [I’ve been saying this for a while:] Physicians are [tribal] leaders, like it or not. But they should not be compared to the captain of the ship; rather, they are the coach of a high school soccer team from which no player gets cut and all must participate.
  • You can calculate fiscal ROI for wellness interventions! At one large academic institution, Resilience training for faculty and staff decreased employee healthcare costs by $450 per person for year over 5 years [I’m pretty sure I got that number right…].
  • Partnering health sciences students with a peer health coach during their training improves their subjective well-being, their biometric measurements, as well as their own confidence in advising patients on lifestyle change.  In addition, the peer coaches also benefited similarly.  [ IT’S ALWAYS A WIN-WIN WHEN WE HELP ONE ANOTHER, HOOOOOORRAAAAAAAAYYY!!]
  • Stress is not all bad!
    • “Threat” stress can be—fight or flight—cortisol, vasoconstriction
    • “Challenge” stress can be good—rise to the occasion—DHEA, testosterone, vasodilation
    • “Tend to a friend” stress can be very good—evokes caring behaviors that help the tribe thrive—increases oxytocin, the hormone of love.
    • Generally we see that people with increased stress die earlier, but it’s actually the subset of those who believe that stress is all bad who do this; those who believe that stress is not all bad actually live longer!

Resilience can be learned. It’s proven!  Let’s get started now!!

A Dawdler’s Triumph

I am a master procrastinator! It’s starting to show on this blog, but oh well, now you know me better. In high school I always wrote my English papers at the last minute, up late in the basement office, typing furiously, feeling giddily anxious under the pressure. In the end I always knew it could probably be better had I started sooner, but it was always good enough.

This time, though, I surprised and alarmed even myself.

Two weekends ago, while hiking happily through golden aspen groves in Silver Plume, Colorado, I realized my presentation to the American College of Surgeons Annual Clinical Congress was only ten days away. Rather than work on my slides that weekend, though, I spent my waking hours trekking through beautiful trails of my home state, with dear friends and family. I returned to the routine of life in Chicago only to realize that my blog post deadline had snuck up on me, too. I had every intention of writing on the camaraderie of friends, sharing stories, questioning, and challenging, all in loving, mutual respect and curiosity. I spent that weekend steeped in tribal love! No presentation slides materialized.

The trail to Pavilion Point, Silver Plume, Colorado

The trail to Pavilion Point, Silver Plume, Colorado

Last weekend I was scheduled to present a poster on physician wellness at the Society of General Internal Medicine, Mountain West regional meeting in Denver. Darn, I had to go back!  But as if my Unicycling post had foreshadowed, I overslept, missing my 6:00am flight and the poster session. The presentation was flung from my lazy Susan, thudding gracelessly to the ground. I felt terrible, as my colleagues in New Mexico had toiled to get the poster done on time, and because of my mistake, their work could not be presented.

You’d think the guilt from Friday morning would motivate me to get working on the ACS slide deck, but no. I spent that evening and the next day with my parents, seeking yet more autumn aspens among which to commune. This took us to the blue skies, crisp air, and vibrant foliage of Vail, and then back to Silverthorne, where instead of working I then proceeded to make greeting cards and bookmarks with my brilliant new leaf collection. I had come prepared with cardstock and packing tape, and I basked in procrastination heaven.

It wasn’t until 9:30 Saturday night that I finally opened PowerPoint. I chose a design and color scheme. I scoured files and Pub Med for data and citations. I consulted my outline, framed weeks before, and sifted through photos to represent main ideas. As usual, I felt an exhilarating mixture of, “Why do I do this to myself,” and, “Man, this could be really good.” By 4:30am, with eyelids of lead and a fair bit of pride, I could finally go to bed, 35 hours before the scheduled presentation.

Along I-70, Eagle County, Colorado

Along I-70, Eagle County, Colorado

So holy cow, what happened? This was a very big deal, I was going to speak to an entire audience of surgeons, for Chris-sakes, and they are no easy crowd! How could I put off preparing for THIS long? For my last original talk, at the Chicago Medical Society Midwest Clinical Conference in March, I had prepared weeks in advance, even allowing time to practice in front of friends before the big day. That was pretty uncharacteristic, but it was also a very big deal. For the first time in my professional life, I was not only presenting data and evidence, but also my own personal thesis on physician resilience—practices that I myself assert as fundamental to our professional well-being. WHY did I not take the same solemn approach this time?

Here’s the answer: FEAR. While not paralyzed, I certainly felt stymied. In my experience, surgeons tend not to think very highly of internists, as a group. Our training is shorter (think, ‘easier’), our hours often more forgiving, and our acute impact on people’s lives less (concretely) measurable. We are deemed less worthy, or at least that is my perception of surgeons’ perception (based on personal experience). So the idea of talking to this group on the ‘soft stuff’ of self-care and overcoming personal adversity made me feel more than a little vulnerable. On top of that, I lack the credentials we all look for in academic speakers: research publications, professor status, institutional titles. Who was I to speak with any authority to people who literally hold our patients’ lives in their hands every day?

By the time the slides were first done, I had determined that everything would be fine if I could just be myself behind the podium. After all, they invited me for a reason—someone had seen my CMS presentation and thought I was a good speaker. I’d better be, after nearly 30 years of practice! I’m relaxed, passionate, and articulate. So hopefully, the audience would just forget about my thin credentials and simply be awestruck by my superior presentation structure and style. Oh and I thought the content was pretty good, too.

I finally discovered my core confidence, of course, through writing. On the plane back to Chicago, I took out my freshly crafted aspen leaf notecards to write to my friends. Having just spent such quality time with them, I wanted to stay connected. It’s what I do. They knew about my upcoming talk, and I wanted to thank them for their encouragement and love. I also needed to confess my apprehension—get it out where it was safe. And I found myself writing, “I may not be the one designing the studies, and I may not have the fancy titles. But I’ve dedicated my whole professional life to helping people find their own agency, no matter who they are or what their circumstances. I know this shit; I live it. I’m the perfect person to talk about this, to anybody!”

Aspen leaf notecards and bookmarks, Vail, Colorado, 2015

Aspen leaf notecards and bookmarks, Vail, Colorado, 2015

Thanks to my remarkable tribeswomen, who hold me up even when I’m 37,000 feet in the air, I no longer question my own worthiness among colleagues in the American College of Surgeons, or anywhere. As long as I am my authentic self, and I do my homework, I can speak to anyone. In the hours prior to the talk I did a fair bit of power posing, just to be sure, and everything went swimmingly. I should also mention that three other women spoke at our session. They told personal stories of adversity and how they overcame. It was truly a privilege to be among them.

I sincerely hope that the ACS will invite more speakers from the ‘cognitive’ fields. I encourage the leadership of the American College of Physicians, the internal medicine professional society, to reach out to our surgery colleagues and collaborate on physician wellness initiatives. I read recently, “The only way to survive is by taking care of one another,” attributed to Grace Lee Boggs, 1915-2015.  Just as nobody overcomes personal adversity alone, and no physician can care for patients without an entire team of dedicated staff, no one specialty will hold the patent on physician wellness. Surgeons’ needs differ from internists’, to be sure, but we can all learn from one another, and the sooner we recognize that, the better for us all.

So, I procrastinate. It’s who I am. And I trust myself to get the job done–well, even. I have a chance at redemption for the SGIM blunder. I will represent my UNM colleagues at the podium of another conference in Washington, DC, in 10 days. I have the outline… Planning to create another PowerPoint file in the next day or two…