Category Archives: medicine

Hope You’re Safe in Chicago

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NaBloPoMo 2018:  What I’m Learning

My friend texted me these words at 4:01pm Central Standard Time today.

Tamara O’Neal, an emergency medicine physician just one year out of training, was shot to death by her ex-fiancé.  He then went on to kill two others, and he himself died, though it remains unclear if he shot himself or died from a police officer’s bullet.  She was on her way to work, saving lives for a living, many of them probably victims of gun violence.

Samuel Jimenez, a 28 year-old police officer, also only beginning his career, was killed.  He leaves behind a wife and three young children.  He was doing his job, protecting innocent lives from deadly violence.

Dayna Less, a 25 year-old pharmacy resident, was also killed.  She was still in training, planning to go home to Indiana tomorrow to celebrate Thanksgiving with her family, and planning a wedding next year.

It could have been my hospital, or my husband’s hospital.  Or one of the hospitals where my sister or my friends or my mom work.  It could have been my children’s school.  An elementary school a few blocks away was locked down until 5pm.  What must that have been like for the kids and their parents?

I was safe in Chicago—today.  But none of us are actually safe, as long as we collectively continue to do nothing about the public health crisis of gun violence that grips and gags us.  And make no mistake it is a public health issue before it is a political issue.  That said, we in healthcare must continue rise up and call for action in policy.  We must demand more of our elected officials.  They must represent us and our collective public interest first and foremost.  A majority of the American public supports common sense gun laws like background checks, licenses for gun dealers, and restricting gun ownership by known domestic abusers.  This should be reflected in our laws and law enforcement.

Please read about the victims of today’s shooting.  Remember them before you read about tomorrow’s victims.  Look up the people who died in Parkland and Pittsburgh.  Put yourself in their shoes, as events unfolded on what started as just another day in their lives.  Imagine what must have flown through their minds—thoughts of children, parents, spouses, regrets, things they wish they had done, things they had looked forward to.  Imagine the terror, the disbelief, the pain, the utter loneliness, the longing for the comfort of loved ones, the wish for another day to be with them, to say goodbye.

Imagine being their family members now, trudging on each day without them, senselessly, with no justice, no closure.  Imagine caring for patients and their families in the emergency department, the intensive care unit, the neurological rehab hospital.  Imagine looking into the eyes of these people, the remaining years and decades of their lives irrevocably altered for the worse by events that unfolded over a few minutes.  And then imagine, as you continue to gaze into their eyes, telling them sorry, there’s nothing we can do about it, this is just the way it is.

The only way enough of us will be moved to take action is if enough of us can truly relate to the experiences of the victims and their families.  Nobody needs to actually live through such horror to be able to empathize.  The human brain is wired for empathy and connection.  At the same time that we cannot imagine what it must be like, we can absolutely imagine.  But we choose to separate, to disconnect, when things are too uncomfortable, to protect ourselves.  This is how tragedies like Columbine continue to happen, every week, every year, for decades.  Not. Acceptable.

Read the American College of Physicians position paper on reducing firearm injuries and deaths.  Apply a critical and objective eye and mind.  Try to understand its reasoning and look up the citations.  Read the appendix, the expanded background and rationale.

Do you want fewer people to die from gun violence in the United States?

What will you do to help reduce the harm?  Because we all need to help.

 

 

 

 

 

Culture of Medicine, Part II

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NaBloPoMo 2018:  What I’m Learning

So, what did you think of how trainees described the Culture of Medicine?  If you’re in medicine, how much did you resonate?  If you’re not in medicine, how much were you surprised, or not?  How do you think this affects our relationships with you, our patients?

Do you wonder how we get through any given day?

I asked the group:  What are characteristics or traits of Culture of Wellness (COW) Leaders?  Once again, I present their responses here, in order of discussion.

  1. “They ask how people are doing.” They are proactive about it, opening the door, making it safe to talk honestly about how we really are doing.  They exhibit the ‘body language of listening.’  It’s still hard to talk about it, one student pointed out.  The best leaders explicitly carve out time to talk, to invite feedback.  It also matters what they do with the information once they get it—empathizing and acting on it if needed, rather than dismissing.
  2. Mentor. This is someone who knows you and whose role it is to help you ‘unconditionally,’ different from any of your evaluators—maybe an advisor.  It can be an informal relationship, maybe just someone you want to emulate.  Trainees agreed that it often happens organically, and they seek it actively.  One resident identified her program director as ‘absolutely a COW leader.’
  3. Walk the Talk. Examples: work/life balance/integration, acceptance of mistakes, admitting when you don’t know something.  NO DEFLECTING; OWN YOUR SHIT.  This one hit home with me—this is Integrity.  As Brené Brown says, integrity is “choosing what’s right instead of what’s fun, fast, or easy.  It is living your values rather than simply professing them.”

The next several descriptors emerged in a flurry.  The atmosphere in the room swelled with positive energy as one label after another of what we admire about our teachers and colleagues overtook the downtrodden mood just moments before:

  • Consistency
  • Proactivity
  • Openness
  • Empathy
  • Personally engaged
  • Curiosity
  • Caring
  • Kindness
  • Vulnerability—willing to share
  • Positivity—seeing mistakes as learning opportunities. Encouraging—“We’ got this!”
  • (Understand the importance of) Food: attending to physical needs
  • Humor—acknowledging the challenge and weight of the work and also holding it loosely
  • Validating
  • Appreciative
  • Grateful

The last one triggered a story.  One student rotated on an inpatient service.  Critically ill patients poured into the hospital; all work hour restrictions were necessarily violated.  Nerves were more than frayed, and people were at their worst.  He witnessed open hostility by senior residents toward interns, backstabbing, undermining.  The attending, present only minimally, was oblivious.  And, “They never said thank you.”  The student, who had planned to enter this field, considered switching.  It was that bad.  But somehow, he was able to get perspective and remind himself that this one bad experience did not represent the whole of this specialty.  It had been an unusually busy month at the end of a long, hard year.  Maybe the cumulative exposure to some of his COWL role model traits had rubbed off, and buoyed him when he stepped onto a leaky boat.

A senior student admitted that when she started medical school she had heard of burnout.  “I initially didn’t believe it could happen to me…  Then later I realized it can happen to anybody—it could absolutely be me, if I don’t take care of myself.”  I asked what that means, taking care of yourself?  They answered:

  • Sleep
  • Nutrition: “Any food your intern year; choices matter more when you’re PGY (post graduate year) 3!”
  • Outside interests
  • Finding a practice situation that fits: eg caring for the underserved, women’s health, hospital medicine, etc.
  • Find Your Tribe. The trainees did not use these words, but this is what I wrote in my notes—they expressed a need for belonging.
  • People at work: truly collegial relationships, especially across specialties
  • Confidants: safe people to share with, your emotional support network
  • Physician-Patient relationships: mutually vulnerable and open

I asked them what they needed to take care of themselves.

  1. Purpose
  2. Time—to be given by the system, and also to be responsible and efficient with themselves.
  3. Habits—established and also adaptible

Overall the discussion felt productive and successful in the end.  We had just mapped out the way(s) to Be The Change we seek in our profession.  Some of them took pictures of my notes (so Millennial), which made me feel gratifyingly connected.  I had tried to question more than lecture, to explore and facilitate more than ‘teach.’  I wanted each of them to own their own path to leading from any chair, now and forever.  I proposed that they could start the moment they walked out of the conference room door—no elevated status or title necessary.

This is why the calling still resounds compellingly, why our enthusiasm for the work persists resolutely, despite the hardships.  It’s Hope.  And at its foundation lies the bedrock of our best relationships—with ourselves, with one another, and with our patients.  On the march toward a true Culture of Wellness, real leaders go in front and set the example.  The rest of us learn by mimicking.  Thus we all have leadership potential and, dare I say, responsibility.  We are the system; we make the culture—each and every one of us makes a unique contribution.  Nothing we do is too small to matter.

Onward.

Culture of Medicine, Part I

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NaBloPoMo 2018:  What I’m Learning

Recently I met with a group of medical trainees from different institutions, ranging from pre-med to senior resident.  The topic was leadership in medicine and culture.  My objective was to lead a discussion on how we see leadership, and to encourage physicians at all levels of training to see themselves as leaders, regardless of designated status.  I often invoke Benjamin Zander’s invitation to ‘lead from any chair.’

We started out discussing the current state of medical culture.  My summary of the labels, in the order we discussed them, follows here.  I strive to hold these observations with minimal judgment, and to practice radical acceptance.  This is simply the way things are, not good or bad, it just is.  That includes how we feel about it all, and that we want to change the parts we don’t like.  Tomorrow I will continue with Part II, characteristics of Culture of Wellness leaders.  For now I invite you, especially my friends in medicine and healthcare, to review the list dispassionately, objectively, from a distance.  See how it lands.  How do you feel reading this list?

  1. Intense
  2. High stakes—we hold people’s lives in our hands.
  3. Imbalanced. When asked to say more, this trainees explained, “It encourages a lack of balance—we are not supposed to mind the long hours.  Our priorities are skewed—we say patients first (but it feels like patients above all else, at any cost?).  There’s the paperwork, the burnout.  You can’t go home if the patient needs you (internal medicine), and in some fields there is no such thing as a shift.  It never ends. (surgery)”  These trainees felt no work-life balance.
  4. Resistant to change. It’s an attitude—“When I was your age…”  Anything different and new in terms of work hours, work load, etc. is deemed bad or inferior before it’s even considered.
  5. Hostile. Between staff members, between doctors and nurses, between doctors themselves, nurses themselves.  The trainees saw this as a key contributor to everybody’s burnout.
  6. Hierarchical—especially surgery (they pointed this out explicitly). For example, walking in the halls, there is an order in which people enter patient or operating rooms.  One student reported entering before her team, because she knew the patient, and making small talk.  Later, she reported, “the senior resident yelled at me, said to go in order, and do not talk to the patient.  In 2017.”  In the OR, when students cut sutures, they must always cut the attending’s suture first.  One medical student was admonished loudly in the OR for this.
  7. “You’re expected to know everything already, even though you’re supposed to be learning on the job.” Trainees agreed that they expect to have to prepare for each day at work.  But as trainees, they cannot always know how to prioritize information as they study in advance for what feels like daily examination.  And they are belittled and shamed for not reading their instructors’ minds and knowing exactly what the teacher is asking for (‘pimping’ the students, as it’s known).  “I never feel like enough.”

At this point you may suspect that I somehow planted the seeds of negativity in these trainees’ minds, goaded them on to blast our profession and everybody who had ever said something mean to them in the hospital.  I assure you I did not, and I marveled myself at how easily these labels flew onto the table.  I hurried to take notes.

Thankfully the vibe circled, as it often does.  One woman commented:

  1. “Family medicine seems actually anti-hierarchy.” Attendings, she observed, often defer to students, who usually know the patients the best, when discussing patient history and data.  Team members may all address one another by first names.  Another student piped in:
  2. Pediatrics is similar. Attendings cover for the team during signout, answering pages and signing orders—everybody pitches in.    On rounds students are allowed to be students—to make mistakes, to show gaps in knowledge.  And a resident pointed out:
  3. In anesthesia, team members take breaks, and she felt a sense of autonomy and support of residents—no shaming. “Maybe it’s the nature of the work,” she said, “it’s easier to tag team.”

Fascinating.  I was practically trembling with excitement—here were ten strangers, from different specialties and at various levels of training, men, women, people of diverse colors and cultures.  And we all had the same experience of our chosen profession, much of it negative.  Yet here we all were, committed and still excited to be doing this work—we all still hear the call.  Whatever keeps us going?  How do we get up every morning and come to work in this ‘toxic’ environment?

I’ll tell you tomorrow.