November 8:  My Students Make Me Better

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NaBloPoMo 2019

Oh how I love my medical students!

Every other year I meet a new group of about 10 third year students, at the dawn of their clinical careers.  What a privilege!  I lead a monthly small group for a class called Personal Transition to the Profession.  I have written about this honor before, describing how

  1. My only job in this class is to love these students into the amazing doctors they are meant to be
  2. They help me see physician burnout from different perspectives
  3. Their experience of medical culture resonates with my own

Monthly group meetings are just enough to start to know any one person after two years, and then they disperse and I grieve the loss, just until my new group starts.  After ten years of stimulating conversations on professionalism and the humanity of medicine, I still feel anxious about my impact on these bright, insightful learners.  Did I do a good job?  Did I make a difference?  Did their time with me matter at all, or was it a monthly waste of time?

This June, I finally faced these questions head-on during a coaching call with Christine.  What are my strengths, what value do I bring?  How can I distill the central learning objective each month?  How can I connect more effectively?  We settled on some ideas for setting expectations and being more direct about goals and touchstones.  I instituted check-ins at the beginning of each meeting, something I should have started years ago.

This month’s topic was open; students were invited to write and discuss whatever was on their minds.  Blog posts and check-in comments resonated around words like exhaustion, sleep, and longing for connection.  So rather than delve into the content of their writing, I simply asked how I could help.  One student, ever honest and forthright, said, “let us go home and get to bed.”  The air felt heavy, almost forlorn… but not hopeless.  I found myself monologuing a few minutes about appreciative inquiry, and finally asked them, a little desperately, “What is the most loving thing someone has said to you this week?” and then, “or how have you felt loved this week?”

Slowly, small vignettes of connection, meaning, and hope emerged.  The student who wanted to get home to bed had received an email from a former preceptor, whose patient finally started and stayed on much needed antidepressant medication, which the doctor attributed to our student’s contact with the patient during his primary care rotation.  Another’s parents had driven into the city early in the morning to lend her their laptop after she had spilled water on hers.  Other students had connected with family members and friends, who expressed pride and encouragement.  Once again I was overcome with love for these young colleagues, and I could not help but tell them:  I have one job here, and that is to make sure you know you’re loved in your training.  I am not here to evaluate you.  You will all finish, you will all succeed.  In the time I have with you, my only objective is to hold you up in the process.  I made sure they all have my cell phone number.  I encouraged them to call me if they ever need anything.

Two students (and one’s wife) came to my house for dinner tonight.  It was supposed to be everybody, but I neglected to send a confirmation email so people weren’t quite sure if I meant my invitation last month (probably because I had planned for them to come over last month and then cancelled on them that week).  We ordered pizza and salad, I fried some potstickers, and we sat around the kitchen island with my kids, just talking.  We are all nerds.  We love to read, to learn.  S’s wife is a resident at my former hospital, and knows my friends there.  They have a book club there now, and this year’s theme is wellness.  She asked for suggestions, so I lent her my copy of My Grandfather’s Blessings.  She and S also borrowed our season one DVDs of The Big Bang Theory.

Our group will meet at a local restaurant after next month’s class.  We will plan (better) another evening meal at my house in the spring.  In the meantime, I will extend an invitation to each of them to come down if they ever need a break from school, a change of scenery, or just to feel a little extra love.  I have been where they are, and I remember how much I appreciated the empathy and compassion of my elders in the profession.  I still do.

How does this all make me better?  In medicine we talk all the time about the calling to care for patients.  But caring for one another, our colleagues and trainees, is equally important.  It keeps us and our souls whole, feeds us so we can keep doing the work.  My students recharge me, inspire me, and keep me young.  What an absolute honor to know them.

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.

Love You Into Being

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A couple of weeks ago I met my new medical students.  These 10-12 trainees will be my small group for the next two years.  We will meet monthly to discuss the soft stuff of medical training—hierarchy, tribalism, death and dying, medical errors, difficult patients, etc.  Some call it “third year medical student support group.”  This is my 6th year of the pleasure and privilege (I inherited my first group halfway through, when their previous preceptor moved out of state).

With each successive group I am ever more amazed at the students’ level of insight.  They articulate compassion, humility, and maturity that I don’t think I had at their level of training. Or maybe it’s because we did not have classes like this to explore such things when I came up (or maybe I don’t remember?).  More and I more I see my role as facilitator more than teacher.  I am not here to impart medical knowledge.  Rather, it is my job to stimulate exploration, conversation, and meaning.  It’s so freeing, really—there is no standardized test to teach to.  And yet I see it as my responsibility to help prepare these gifted young people to face the greatest challenge and reward of the profession: human relationships.

I feel no fear or trepidation.  We cannot ‘fail’ at this class, any of us.  Because the point of it is simply for everybody to participate, contribute, consider, and learn—myself included.  Each month the students are given questions to answer in the form of a blog post.  For example, “Recall an example of inspiring or regrettable behavior that you witnessed by a physician.  Describe the situation, and its impact on you, the team, and/or the patient.”  I read them all and facilitate discussion, tying together common themes and asking probing questions.  My primary objective is to help them maintain the thoughtfulness and humanity that led them to medicine in the first place.  Medical training has evolved in the past 20 years, for the better in some ways, not so much in others.  One way we do much better nowadays is recognizing the hidden curriculum, and shining light on its effects, both positive and negative, through classes like this.

We all have those teachers who made a difference in our lives—or at least I hope we all do.  I have multiple: Mrs. Cobb, 4th grade; Mr. Alt, 7th grade math; Ms. Townsend (now Ms. Anna), 7th grade English; Ms. Sanborn, 7th grade social studies; Mrs. Stahlhut, 9th grade geometry; Mrs. Summers, 10th grade English; Coach Knafelc, varsity volleyball; Dr. Woodruff, primary care preceptor; Dr. Roach, intern clinic preceptor; Dr. Tynus, chief resident program director.  My mom is one of these teachers, also.  She leads nursing students in their clinical rotations.  I have seen her student feedback forms—they love her.  And it wasn’t until I heard her talk about her students that I realized why they love her and what makes her so effective—she loves them first.  Teaching is often compared to parenting.  Our parents, at their best, see our potential and love us into our best selves.  They cheer us, support us, redirect us, and admonish us.  They show us the potential rewards of our highest aspirations.  If we’re lucky, they role model their best selves for us to emulate.

All of my best teachers did (do) this for me.  I’m friends with many of them to this day, and I still learn from them in almost every encounter.  I love them because I feel loved by them.  They held space for my ignorance and imperfections.  I always knew that they knew that my best self was more than the last paper I wrote, the last test I aced, or the last patient encounter I botched.  To them, my peers and I were not simply students.  We were fellow humans on a journey of mutual discovery, and they were simply a little farther along on the path.

This is my aspiration as a teacher, to live up to the example of all those who loved me into the best version of myself today.  This kind of love allows for growth and evolution, from student to colleague, to friend, and fellow educator.  This is not something attending physicians typically express to medical students, positive evolution of medical education notwithstanding.  But when I met this new group, I was overcome by love for them.  So I told them.  “If you take away nothing else from our two years together, I want you to have felt loved by me.  I wish to love you into the best doctors you can be.  That is my only job here.”  Or something like that.  It was impulsive and possibly high risk.  But it was the most honest thing I could say in that moment, my most authentic expression of my highest goal for my time with them.  I only get to see them once a month, and I want them to be crystal clear about what I am here to do.  We have lots to cover these two years, so much to learn and apply.  And love is the best thing I can offer to hold us all up through it.