Category Archives: Uncategorized

Culture of Medicine, Part II

Posted on by
5

IMG_4481

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

Posted on by
1

12657_4331869529492_1472680046_n

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.

Frass, Trauma, and Other Stuff

Posted on by
2

DSC_0542

NaBloPoMo 2018:  What I’m Learning

Can’t think of anything useful to write today…  Or rather, I’m too tired to make any half useful thoughts into enough coherently connected sentences to be worth publishing.

So I’ll share some small things I have learned recently, which I find interesting.

Frass

Noun.  Fine powdery refuse or fragile perforated wood produced by the activity of boring insects.  The excrement of insect larvae.

I have a wonderfully smart and kind friend who conserves paper for a living.  Do you know any expert paper conservators up close and personal?  If so then you know the exquisite mind and temperament it takes to do this work.  She must possess the exacting scientific leanings that comprehend both biology and advanced chemistry (inorganic and organic).  She holds the vast sweep of art history, especially as it applies to paper and ink as media, at her fingertips.  And her appreciation for the uniqueness and intrinsic value of every piece drives her pursuit of the end product.  She must command all of this knowledge in an integrated fashion, bringing to each new project confidence, curiosity, and love.  And when she works on an old map in the library archives caked with dust and soot, and tells her friend about the project, she teaches her friend the word frass.

Getting out tree sap and other cool tips

You probably already know about using Coca-Cola to clean toilets, and salsa or ketchup to shine pennies and silver.  But did you know that olive oil and butter get out tree sap, and mayonnaise gets off glue residue?  Unbrewed coffee grounds absorb mildew if you leave them in an open container at the bottom of a closet for several days.  Vodka works well for getting smells out of clothes.  And rubbing your hands with salt can get out the smell of onion or garlic.

Toxic gaslighting

I only learned the word ‘gaslighting’ after the 2016 election.  *sigh*

The word was among the final contenders, apparently, for the Oxford English Dictionary’s 2018 Word of the Year.  But ‘toxic’ won.  Says the head of the company’s US dictionaries, “the word was chosen less for statistical reasons… than for the sheer variety of contexts in which it has proliferated, from conversations about environmental poisons to laments about today’s poisonous political discourse to the #MeToo movement, with its calling out of ‘toxic masculinity.’”  Last year’s WotY was ‘youthquake.’

Trauma

Last weekend I spent time with a wonderful residency classmate and her amazing family.  She is the Chief Medical Officer of a large health system that serves a population with a high prevalence of mental illness and substance abuse.  I got to hear about her passionate and profoundly important work educating and advocating for trauma-informed care, which I am only starting to learn about.  Interestingly, NPR had just posted an article detailing findings of a study published in the Journal of the American Medical Association (JAMA) showing that childhood trauma is strongly associated with poor adult function outcomes, such as mental illness, failure to hold a job, and social isolation.  By age 16, 31% of children in the study had had one traumatic exposure, 22.5% had had two, and 14.8% had had three.  What does that look like at the doctor’s office?  Read the Harvard story of the two kids and their vaccines here.  What can we do about it, as physicians and society?  First, recognize the prevalence.  NPR asked, “Should childhood trauma be treated as a public health crisis?”  The answer, unequivocally, is yes.  Second and always, practice curiosity and empathy. Every day.  All the time.  Again and again.  If someone is acting out, before judging them for being difficult and ruining your day on purpose, ask what could lie behind the behavior.  Everybody deserves and benefits from a little concern and gentleness. And if you’re a healthcare professional, start with the Harvard article, and then read this one from the National Council for Behavioral Health.  We all need to treat each other better.  So much better.  Please.

So, what interesting thing(s) have you learned lately?