3 Great Articles From The Generation Y Surgeon’s Reading List

By:  The Generation Y Surgeon (@GenYSurgeon)

 

The internet is littered with articles about doctors and medicine…some good, some not so good.  I enjoy reading them, regardless of quality.  With the growth of social media and the prevalence of internet-based communications in medicine, the web has quickly become a new voice for physicians.  Most importantly, it’s a better way of communicating with the non-medical public.  Much of medicine remains a mystery to laypeople, especially when it comes to the daily life of physicians (and all other providers and ancillary medical staff for that matter).

Informal articles are frequently damaging to providers; however, some can actually be quite revealing to the public. With the constantly changing landscape of healthcare, it’s becoming more important to tell our side of the story.  Below are a few of the articles that recently caught my eye.  Enjoy!

 

(1) How Do Clothes Influence What Patients Think About Us? 

 

http://www.theatlantic.com/health/archive/2014/12/the-clothes-make-the-doctor/382866/

 

This article is symbolic of the many hats physicians are required to wear in modern medicine.  It also very clearly identifies some of the hurdles we face.  I sympathize with female physicians, as their wardrobe and image situation is much more complicated than that of male physicians.

 

(2) Where Does The Physician’s Responsibility End?

http://www.amednews.com/article/20130715/profession/130719980/2/

 

This article really strikes a nerve.  I’ve wondered for a long time, where is the line between my my responsibility for patients and their responsibility for themselves?  What do you think?

 

(3) Feel Like You’re Struggling Against The System?

 

http://www.kevinmd.com/blog/2014/09/hospitals-discourage-doctors-step-step-guide.html

 

Great article.  Period.  Every provider I know can sympathize with this article.  When you feel as though you’re struggling against the system…it’s because you are.

Do you have any articles to share with the group?  Please reply with links to anything you’ve found interesting.  I look forward to hearing your thoughts!

Do We Deliver Great Care Even At Midnight?

 

By:  The Generation Y Surgeon (@GenYSurgeon)

 

Sick Patients Highlight The Issue

 

It was 1:00am, and I was at bedside with a complicated post operative patient in the ICU who had recently presented with upper gastrointestinal bleeding.  The resident surgeon and I (I’m a fellow now) were on the phone trying to get in touch with nuclear medicine, with GI, and with interventional radiology…and none of them were answering.  Ten minutes passed.  Then twenty.  I timed it because when patients are as sick as this guy, every minute feels like an hour, especially when you’re waiting for a call back.  I was curious how long it would take them to return a call.  Any of them. Why had all of our consultants turned into pumpkins after midnight?  This patient needed their help–and he was sick.

 

Two Hats & Misalignment

 

I can sympathize with providers who are forced to wear two hats: the elective, daytime hat and the emergency responder, middle-of-the-night hat.  The gastroenterologist I call doesn’t just have to get out of bed in the middle of the night, they also have to face a full day of elective cases and clinic patients in the morning.  The interventionist calls in an entire staff and is often left to struggle through elective procedures with a skeleton crew the following day.  The aftermath of responding to midnight consults must be a terrible deterrent for them.  Sympathies aside, many midnight consults cannot wait to be seen in the morning and patient welfare is at stake.

 

Oh, by the way, many docs are reimbursed related to the number of cases they do (and RVUs they produce).  Would it make sense for them to struggle for a few extra RVUs that are hard to get when it’s 2AM and the patient is critically ill only to struggle more to do the rapid turnover, elective cases the next day?  God forbid you’re so tired from the midnight work for that patient that you have to cancel some elective cases for the next day.  Does it make sense to them to work hard at 2AM with this patient and phone call, or instead just to sleep and focus on the elective “daytime hat” cases that their contract incentivizes them to do?  Could those same docs be faulted if they adopted the “they wouldn’t have survived anyway” mentality that I so commonly see providers use to make themselves feel ok about the difficult situation they’re in?  Yes, some people will pass away no matter what.  However, in one system in which I’ve worked, even people who “wouldn’t have survived anyway” did survive–and it was because the system was setup properly.

 

Hospitals really need to make sure they are incentivizing the kind of behavior that leads to the best (yet often labor intense) outcomes for critically ill patients–because, now, sometimes they don’t.

 

A Lesson From Taco Bell That We Should Learn

 

Did you ever notice that (if you need gas or a snack) there’s always a gas station open?  If you feel the need to harden your arteries at 3am, there’s usually even a Taco Bell that’s both waiting and willing to help you.  Walmart’s doors are open 24/7 (and holidays too!) for electronics, groceries, household items or people watching.  You can even get photos developed.  Why aren’t hospitals that provide care for critically ill patients 24/7 entities as well?  People need healthcare around the clock, emergencies don’t wait.  Maybe it doesn’t need to be all hospitals, but the ones that take care of sick people need to get this right.

 

By the way, did you know trauma tends to be “a disease of nights and weekends”? If you look at many trauma programs (that care for critically injured patients when time is short), there’s often an influx of patients at night time and on weeknights.  Those are the busy times.  And when are those programs the most short-staffed?  You got it:  those same nights and weekends.

 

Here’s an exercise: knowing what you know now as a provider (and assuming you had all the power and influence you would need) think about how you would run a hospital?  How would you schedule your physicians and staff?  What would the hospital look like at 8am, at noon, at 4am, or on Sundays?  Obviously, things need to change.

 

One System To Help Them All

 

Changes in a hospital system are tough to perform (there are some useful steps described here on the blog); however the Acute Care Surgery model (ACS) is an excellent example of positive change.  ACS is more of a system than a specialty.  Hospital with well-run programs are able to provide consistent access to surgeons for both patients and for consulting teams.  ACS also serves a sort of triage service for acutely ill patients, taking much of the brunt for their daytime colleagues and even for the consultants.  It turns out that general surgeons actually end up doing more cases when they aren’t burdened with emergencies that interrupt their flow and consume resources.  Having a fully-equipped surgeon who specializes in emergency care (and knows when and why to call in consultants) as part of a system is much more effective than other processes of dealing with critically injured or ill patients.  Having a provider like an ACS surgeon in-house takes a huge burden off the system, and the entire system grows in terms of cases performed even as the overall quality improves.  It’s the only real 24-hour specialty outside of emergency medicine.

 

Now You Know, So You Must Act

 

Our patients need us 24/7, so shouldn’t we be adequately staffed to provide care 24/7?  Shouldn’t the hospital be more like a Wawa (or Sheetz) than a bank?  In a perfect world, it would be….with the hum of the hospital sounding exactly the same, regardless of the hour or the day  or day of the week.  We should aim to get great outcomes for everyone all the time and now we face a choice because we know what it takes.  And so now we are obligated to act on what we know.

1 Key Tool To Influence Decisions

 

Generation Y Surgeon

 

 

 

By:  The Generation Y Surgeon (@GenYSurgeon)

 

 

 

Yes, You Negotiate Every Day

 

Whether you know it or not, negotiation takes up a huge part of your day. You negotiate with other attending or consulting physicians, nursing, administrators, insurance companies and even with your patients. Negotiation is an invaluable skill, and learning how to negotiate will save you time and headaches. I strongly recommend reading Getting to Yes and/or Getting Past No by William Ury. Both books are short, easy reads and are quite fun to apply to your daily interactions.

Over the years I have learned what works (and what doesn’t) when I interact with my patients and, to some degree, with my colleagues. It wasn’t until I read Getting Past No that I was able to put it into words. If only I had read this earlier!

 

The Golden Bridge Technique

The entire book is gold, yet learning how to build a “golden bridge” remains my favorite tool. I find it most useful when I’m in disagreement with a colleague or when dealing with difficult families. What does it mean to build a golden bridge? It refers to making sure you have satisfied the demands of the four most common obstacles in coming to an agreement:

 

(1) involving the other party (or parties) in devising a solution

(2) meeting unmet interests

(3) helping them save face

(4) and making the process as simple as possible.

 

 

Building The Bridge

Now think of all the situations to which you can apply this skill. Think of your last interaction with a difficult patient or decision maker. Were they overwhelmed and feeling powerless? Did they truly understand the situation and consequences? Were their expectations reasonable or unreasonable? Was there something about the patient or their family that was important to them and unknown to you? Had they previously acted in a way that was embarrassing or damaging? Had they somehow offended you or your staff during a stressful situation?

 

…For The Patients

We have all dealt with patients (or their families / representatives) who have felt like this. One way to augment your interaction with them, especially in times or stress, is to build that golden bridge. Involve them in the decision making process by asking about their expectations and realigning them early on. Prod them for information on their concerns and wishes so that you become aware of any unmet needs. If they acted rudely or made outrageous demands, then let them know it’s ok. Give them a chance to save face by allowing them a fresh start and by all means, do it with empathy. Chances are this is the worst day of their life (and just another regular day in yours). Finally, boil the options and interests down into a few simple choices. When you are able to provide your patient with a few simple choices (that they “helped” to create) you will find that everyone is happier with the outcome.

 

…And For The Docs

Now think of the last time you disagreed with another provider…no matter how hard you tried, you couldn’t convince them to accept your idea or plan. They resist because they weren’t involved in the creation of such a great idea, and allowing you to be right may make them feel like they’re in the wrong. Their interests in maintaining control over the patient or care plan is not met by accepting your plan as the best, and of course that takes a bit out of their ego. Next time you encounter this situation, try building a golden bridge. The conversation may go something like this:

 

” Dr. Bossman, do you remember when you taught me about Treatment-X? We applied Treatment-X to Patient Y and it really worked great. Could we talk about how that may work for our current patient?”

 

…and voila. You’ve engaged them in the decision making process while allowing them to both maintain control and save face in front of the group. As an added bonus, you’ve reminded them of another time when they made an excellent choice which will also increase your influence over their present decision because they will want to be consistent with “their” previous choices. Wouldn’t it be nice if all your negotiations in hospital could go this well?!

 

Build The Bridge…For Their Needs And Your Success

In closing, I will again urge you to invest some of your time into reading a little more about negotiation. It’s a skill that most providers undervalue even though they use it everyday. In the beginning, using advanced tools like the golden bridge may feel like manipulation–however it is NOT. Yes, we all know that the surgeon’s ego is strong (and it has a purpose), but this technique is about influencing things when, at times, other people’s issues may be getting in the way of the best outcome.  Negotiation is not about winning arguments or getting what you want, it’s about coming to a solution that maximizes results for everyone. Try it!

Would You Know If You Were Incompetent?

 

By:  The Generation Y Surgeon (@GenYSurgeon)

 

There’s more to business than dollar signs and sales–a lot more.  Within the broad discipline of business, there is a focus on people: how they think, how they interact, why they do the things they do and how to get the most out of each and every member of the team.  Teamwork, interpersonal relations and communication can make or break even the strongest of businesses and as a result, our friends in business have invested a lot of time and energy into learning how and why individuals and teams fail or succeed.  

As providers we are required to function within teams. The environment is stressful, the stakes are high, the time crunch is unrelenting and our partners/coworkers can be challenging to work with.  There are tools available to help alleviate these problem interactions and inefficiencies yet very few of us use them.  Worse yet, we don’t even know where to look for help.

For my next few blog entries I would like to share some of the concepts and skills that I have found to be most useful in the hospital and clinic.  Thinking about our workplace in a different light, and learning just a few new tools to deal with people and stressful environments, can lead to positive changes…if you choose to experiment with some of these tools.  I challenge you to take these concepts and ideas into your own workplace and use them to create a happier and more efficient workplace for yourself and your healthcare team.

 

The Dunning-Kruger Effect

 

The Dunning-Kruger effect is one of my favorite proposals, especially when you think about what it means to providers, to medical education and to our own personal development.  If you’re not worried about your own personal performance after learning about this then, well, you have a problem.

The Dunning-Kruger effect is a cognitive bias whereby unskilled individuals suffer from illusory superiority, mistakenly rating their ability much higher than accurate.  (More about it here in that classic tome of knowledge, Wikipedia.)  Highly skilled people, however, tend to underestimate their competence and wrongly assume that tasks they find easy themselves are also found easy by others.  In other words, the unskilled don’t realize they are inept and the skilled undervalue their skill.  Again, this is a cognitive bias and it’s related to confirmation bias, meaning that people see what they want to see and ignore what they don’t want to see.  Most people believe that they couldn’t possibly be wrong or less intelligent than others so they develop an artificially inflated sense of self-esteem.  Unfortunately, this shields them from recognizing their own lack of skill, the extremity of their inadequacy, and the presence of genuine skill in others.  For these reasons, the incompetent tend to stay incompetent.

Think for a moment about what this means.  Try to remember the last time you felt truly competent and confident in your abilities…were you actually competent or blinded by your own ignorance?  Now think of the last time you felt inferior to your peers…was that your shining moment?  So…are you second-guessing yourself yet?  The good news is that you’re probably not as inept as you sometimes think you are…Yet, on the flip side, you may be lacking severely some skills without even knowing it!

Understanding the Dunning-Kruger Effect is the first step, now let’s apply it to a couple of scenarios:

 

-M&M conferences:  Providers know a lot and pay special attention to learn from mistakes.  According to Dunning and Kruger however, the inept are unable to recognize their own lack or skill, the extremity of their lack of skill and the presence of genuine skill in others…did you ever wonder why so many M&M’s repeat themselves?  It’s because some of the people in the audience are unable to see their ineptitudes and therefore fail to learn.  Wise physicians will tell you “know what you know, and more importantly, know what you don’t yet know.”  Incompetent physicians cannot fathom that there are things they do not yet know.

-Public opinions on vaccines and gluten-free diets:  As a provider you understand the science behind viral disease, vaccinations and how they impact the public’s health as a whole.  As a provider you’ve also seen the public refuse such vaccines.  Have you ever tried to explain the risk/benefits to someone who refuses vaccination?  Regardless of the data supporting influenza as a leading cause of death across all age groups, some people just cannot grasp the concept of vaccination.  We have been educated in virology, genetics, epidemiology and statistics and we’ve seen patients die from preventable causes.  Most patients have not.  This is why arguing with non-scientists about topics such as vaccination is so frustrating!  Because they have not been exposed to the skills/knowledge it requires to fully understand the topic they are unable to understand…and they don’t even realize how little they know!  They are so blinded by their lack of skill/knowledge in the topic that they cannot even see that they lack skill/knowledge.  (As an aside, I respect all educated decisions about vaccination…unfortunately most people who refuse vaccination are not equipped to do so.)

Now you know what the Dunning-Kruger Effect is and how it affects our daily lives.  You should find this concept unsettling because it uncouples perception and performance, leaving you wondering where you stand among your peers.  How can you correct your ineptitudes if you don’t even know you’re inept?!  Well the good news is that Dunning and Kruger also proposed that incompetent people will recognize and acknowledge their own previous lack or skill IF they are exposed to training for that skill.  So keep your eyes open and embrace those feelings of inadequacy…if you don’t feel incompetent sometimes you just might be, well, incompetent!

I hope you enjoyed this blog and learned a little something.  Take this new knowledge with you into the hospital or clinic and use it to better understand yourself and others.  And take it easy on yourself the next time you underestimate your own skill.

Use Different Tools To Help The Underserved

By:  The Generation Y Surgeon (@GenYSurgeon)

 

Medical School Orientation Taught Me Many Lessons

My medical school orientation was quite the to-do.  There were lectures, dinner, team building exercises, and even a field trip.  The field trip was what had the most impact on me, and not for the reasons you’re thinking.  The impact was all negative for me.

The entire medical school class packed into tour buses and we drove out of the city to a small community hospital teeming with “underserved” patients.  We were taken there for the shock factor: the facility was crumbling, the clientele was poor and unhealthy, the community was violent and drug-ridden yet the community leaders were trying hard to make big changes.  It was terrible and beautiful at the same time and a hundred-and-twenty-some bleeding hearts looked on.  So why was this such a negative experience?  Because I was born at that hospital, that’s why.  Because my family lived in that area, that’s why.  Because the people there recognized my family’s faces in mine without knowing me and it was embarrassing.  I was surrounded by seemingly good-hearted people who, without saying it, felt as though they were better than these “underserved” people.  I was unable to identify with either group because I was clearly no different from these people yet I was not “underserved”.  I had simply found a way around a certain set of barriers.

 

Reflecting On The Term “Underserved”

Remembering this, I began thinking about what it means to be underserved and now, after 10 years of training, it’s time to re-explore the definition.  In my opinion, to be underserved is not to lack resources, it’s to lack access to resources; to serve the underserved is not to give resources, it’s to eliminate barriers to resources.

Early on in our medical training we are taught to pay attention to the underserved and we are even taught about who they are: black people, poor people, rural people, non-English speaking people, abused women and children.  We are taught to feel for them…but we shouldn’t.  Underserved populations are groups of people who have identifiable barriers to obtaining healthcare, barriers that as physicians, we need to address in order to properly care for people.  How we feel has nothing to do with it.  In fact, you could argue that having feelings towards any group of people clouds your judgement and makes it harder to be objective.  Step back for a moment and think about what it means to be underserved…it’s about barriers to healthcare.  As physicians our job is to eliminate those barriers so that underserved populations have access to care; it’s not our job to just feel for them and give away healthcare.

 

Think I Lack Empathy?  Read On…

You’re probably sneering at what you perceive to be my complete lack of empathy, but that’s ok.  Let me remind you of all the ways that we are similar: we are doctors, we have sacrificed years to training, we put others before ourselves, we care about people, we want to make a difference in as many people’s lives as possible…

 

Now let’s think again about being “underserved” really means to us as physicians charged with helping those around us, those dear to us, and those that are hidden from our sight by barriers.  For example, take a look at physicians.  Compared to all American men, male physicians have more than twice the prevalence of hyperlipidemia (12% vs 35%).  Forty-two percent of physicians have hypertension compared to 28% of the general public.  Among female primary care physicians, approximately 20% have a history of depression and suicide continues to be a disproportionate killer of physicians.  Shocking numbers for people who work in hospitals and doctors offices, and this doesn’t even begin to cover all of the gaps in healthcare for healthcare providers.  How many times did you go to the dentist in medical school and residency?  Exactly my point.  Obviously there is some barrier to physicians receiving adequate healthcare…so are we an underserved population too?  We’re not getting what we need, not following advice, or have some other barrier…

 

Why Does This Fit On This Blog?

You may be wondering why I’m writing about this in a business and innovation blog.  The point is to highlight a set of skills that already exist in the business world–skills that you are likely overlooking in your process improvement and safety lectures/meetings.  Tools like root cause analysis or Ishikawa diagrams can help you identify the right problem.  Process improvement exercises could streamline your practice and extend your abilities to see patients.  Pulling data from your very own practice and analyzing it may identify barriers that exist in your very own office.  Taking this knowledge base into the community and using it to maximize the efficiency of hospitals, like the hospital I was born in, has the potential to touch more patients than you could ever dream of seeing in your own practice.  To be “underserved” isn’t about being poor or black or beaten or far away from a hospital; it’s about being stuck behind barriers.  As physicians, we can help more people by identifying and breaking down barriers than by simply stepping over them, because at the end of the day the barriers will still exist.

If you really want to make a difference and extend your influence as a healthcare provider, then use some tools from business world.  We don’t get paid to feel bad for people, we get paid to help people and the best way to do that is to be objective and remove barriers so that we can see who really needs us. I challenge you to start thinking of the “underserved” in a different way and begin tackling their barriers to healthcare in a strategic manner.  If you can correctly identify what stands between you and your patients (or colleagues!) then you will have a much better shot in removing that barrier.  Take a closer look at David’s blog entries for more information…the tools he describes can be used for much more than business if YOU apply them correctly.

 

We All Fail When A Resident Fails Boards

By:  The Generation Y Surgeon (@GenYSurgeon)

This post is for surgeons, surgical residents and future surgeons.  This post is more than a rant–it’s information.  For surgeons and residents, this should be a wake up call. For my future surgeons, this is what no one tells you before match.  Please read on and take the time to comment because I’m interested in your thoughts…

Venturing Into The Light To Take The Test

It’s board season.  Well, it recently was boards season.  This is when tired and bitter chief residents first enter the ranks of the attendings (or fellows) and the dinosaurs emerge from their clinics, operating rooms and labs to re-certify.  No one is spared…the chairman, the worker bee, the non-operative surgeon, the researcher….everyone must participate at some point.  A mountain of paperwork, $1400 in registration fees, and 320-something questions for one exam with very high stakes.

18% Fail?!  Are You Kidding Me?!

Let’s talk a minute, however, about the results of the boards.  Per the ABS, pass rates are, at best, 82%.  So 18% do NOT pass…that means 1 in 5 fail!  Whether you’ve passed or failed, taken the exam once or thrice…you shouldn’t feel good about our testing schema.  What does this failure rate say about our training programs and surgery as a profession?

The way I see it this means one of three things:

One in 5 board eligible surgeons are retarded.

The exam is too difficult, too tricky or is testing information that is not included in surgical training. 

We aren’t teaching residents what they need to know to be considered a passable surgeon–or we’ve just testing them in a whacky way.

Obviously, by the time someone is taking their surgical qualifying exam, we can assume that they aren’t retarded.  So that leaves point 2 and 3 to discuss further.  First, consider the exam itself.

 

What Is The Purpose Of The Boards Really?

Start by asking yourself, what is the purpose of the surgical boards?  The boards should be a final test that double checks the core knowledge that all surgeons should have mastered.  The boards should cover the concepts that keep our patients safe.  The boards should demonstrate that our residents are trained appropriately and can uniformly pass a straightforward exam designed by senior, practicing surgeons.  It should not be a tricky exam that stratifies good and poor test-takers.  It should not be administered to any person who hasn’t already demonstrated adequate knowledge and skill.  Basically, this exam should be nothing more than a checkpoint for those who have performed adequately during their 9+ years of training–not an exam that lets good surgeons fail and poor clinical performers squeak by with good test taking skills. 

Seriously, should we feel ok about a fail rate of 20%?  Do you know anyone that is so far behind that they should fail?  We are all very smart people, skimmed off from the top of our undergraduate classes and funneled through the most competitive schooling and training to attain doctorates.  If surgeons can’t teach smart people to be surgeons then who can?  And if you know a resident or practicing surgeon who has fallen behind the curve, how long did it take for them to be left behind?  How long were they allowed to train before someone intervened?  Is their failure ignorance or is it failure of the system to identify and remediate theses surgeons appropriately?  Remember, we are a profession.  Therefore it’s our job to police ourselves and maintain the standards by which we mean to present ourselves.

 

When Someone Fails, It Means We All Failed Together As A System

After 9+ years of education, a surgeon who fails their boards represents more than a person who has inadequately prepared, it represents a person whom the profession of surgery, or at least a training program, has failed…and, oh, if the training program / profession says that person just wasn’t good enough?  Well, why don’t we select residents (future surgeons) well enough to only allow people in who will succeed?  Aren’t we, as people who help train others, good enough to select people properly?

Now here’s a challenging statement: if we did a better job of educating our future surgeons (or at least selected them properly), then after 9 years (4 medical school + 5 residency = at least 9!) there would be no point in even having a board exam.  All of the necessary knowledge and skills would have been demonstrated by each resident by the time they were able to graduate.  There’d be no need for the “final test.”  Did that blow your mind?  Yeah.  This is where the ACGME is really starting to do something right.  With the institution of the “milestone” system of resident education and the growth of the SCORE curriculum (however painfully primitive that website remains), focus is finally shifting toward the quality of time spent in residency while using appropriate measures of competency.  Unfortunately they missed one big thing…no one has taken the time to teach our teachers how to teach.  Once again, the profession of Surgery, despite its good intentions, has fallen short. 

To my generation-Y resident, medical student and junior attending colleagues:  I’m interested in what you have to say about this topic.  Old guys / Dinosaurs:  I’m interested in your perspective as well because you have seen more change in Medicine and in surgical education than the rest of us.  Please take the time to comment below!

-GenY

Surgeons: Don’t Ignore This Severe, Treatable Disease!

By:  The Generation Y Surgeon (@GenYSurgeon)

 

With all of the media hype regarding Robin Williams’ suicide, I thought it appropriate to bring up a topic that I find quite important. Physician suicide.  If you think that’s not a good blog topic, or that we shouldn’t talk about it–or even that you don’t want to hear about it–then you are DEFINITELY the person who should read on.

 

Mental illness knows no boundaries.  Whether you are a famous actor, a child, a homeless person or even a physician, depression and suicide destroys lives. Why is this in a blog regarding business models and hospital systems? Because this is an example of a way we can improve our system. Any profession that allows the loss of one of its own can be improved. I don’t know how to fix it but I hope someone else does. In the meantime, let’s start a conversation about it…because awareness is a good start.

 

A Setup For A Bad Outcome

For (at least) five years, “the future”meant “next weekend”. Knowing your call schedule for the month before the month started was a luxury, and even then it could change at any minute. Financial planning consisted of paying your bills and keeping your bank account above zero. Living a healthy lifestyle meant having (not necessarily using) a gym membership and sleeping for more than 4 hours on six out of seven nights. The future meant surviving each shift by looking forward to your sacred 24 hours off, and not much else. Emotional stability meant you showed no emotion.

 

Physicians, and especially surgeons, do not do a great job of caring for themselves. During our training we defer our salaries, postpone our personal goals, set aside social commitments and are often forced to plan our lives month by month. Residency is consuming and exhausting and seeing beyond graduation is enough of a challenge, seeing to the ends of our careers is nearly impossible.

 

Surgeons Do Very Little To Protect Themselves

For all of the emphasis on anticipation and prevention in surgery, for as hard as we work to protect our patients, surgeons do very little to protect themselves. Surgery is emotionally and physically draining. The burnout rate for surgeons is abnoxiously high and likely underestimated. And the physical cost of long hours, late nights, navigating large hospitals and hands-on patient care is not insignificant. Due to the training required and the intensity of the job, surgical careers start late and end early. And we do very little to protect ourselves from, well, ourselves.

 

Ut Oh:  The Facts Of The Matter Make Us Pay Attention

Here are some alarming facts courtesy of the American Society for Suicide Prevention:

  • In the U.S., suicide deaths are 250 to 400 percent higher among female physicians when compared to females in other professions.
  • Among male physicians, death by suicide is 70 percent higher when compared to males in other professions.
  • In the general population, males complete suicide four times more often then females. However, female physicians have a rate equal to male physicians.
  • Women physicians have a higher rate of major depression than age-matched women with doctorate degrees.

 

This makes me sad. (Don’t worry…not that sad.) We spend our days and nights and weekends snatching people from the jaws of death, yet we let our own people die the most painful deaths? Think for a moment about what it is like to suffer so much that you take your own life…what terrible suffering that must be. To know that physicians, strong and intelligent and persevering people like yourself, have taken their own lives? The loss of life, of talent, of influence in a community….truly a waste.

 

Focus On Surgery

Physician suicide is a problem across all specialties, but I want to talk specifically about surgery. Surgery is a tough sport because it preys on weakness and always finds our weakest point.  Long nights, high stakes life-or-death situations, empty stomachs, harsh critics and strict deadlines. As a surgeon, the amount of stress we face on a daily basis is already too much. Add to that the emotional stress of seeing people die and families mourn, the associated accountability and feelings of guilt, and the “extras” like M&M, ABSITE/boards and interviews which get tacked onto the “side.” The life of a surgeon is unforgiving to say the least and our training prepares us for much of this, but it doesn’t make us immune to stress and depression. As much as I hate to admit it, surgeons are just people…and we have limits.

 

On top of the stress inherent to the job, societal stresses and double standards have further isolated us emotionally. For example, take the snide comments regarding our paychecks. I’ve been told by more than one patient that doctors make too much money, and I’ve admittedly felt a little ashamed. However these patients don’t know that most medical students have over a quarter million dollars of educational debt, that residents can’t always pay all of their bills, that our “huge”paychecks don’t start rolling in until we are in our 30’s. To be attacked by the very people you are trying to help is an added stress and it takes an emotional toll whether conscious or subconcious.

 

Another issue is our lack of support from the public, other hospital staff and even our own families. The truth is that no one truly understand what it costs to be a physician. We sacrifice our 20’s to school and eventually to residency, we work when our patients need us and sacrifice our own lives for their sake, we endure years and years of stifling training and sacrifice time and youth inside the hospital…and yet no one really understands.

 

Is what I’m saying making you uncomfortable? Unfortunately, that’s how it goes when we stop and look at what we do.  Probably still worth it to look at what we do instead of ignoring our situation.  After all, maybe if we acknowledge the challenges we can work to avoid those preventable deaths.

 

The Paycheck Issue & Lonely Days

Truth is, no one offers any sympathy because all they see is the big paycheck, the fancy car and the letters behind our names…and they forget that we have earned it. The luxuries we afford ourselves have been delayed by years and even those luxuries are used against us in underhanded ways.

 

Surgery, specifically residency, is also a lonely time. Even though we work with people every day, we lack the time we need to build and sustain healthy relationships with family and friends. Our work schedule prohibits the downtime that is need to maintain stability. For those of us that are married, we take time from our families and give it to strangers. For those of us who are not married, an empty house and a limited social life is expected. For for the women who deal with the stigma of being unmarried, or being child-free while living and working in a male dominated field…well, I’m sorry you have to deal with that.

 

The truth is, surgery is isolating and dangerous. It is a setup for depression and suicide, yet at times it seems we have done little to prevent it. All surgeons go through the same trials, some face more difficulties than others, and even the “easiest” of careers is maximally stressful compared to the general population. I would venture to say that most of us, somewhere along the way, have dealt with some degree of depression. But why don’t we talk about it? Depression and suicide are taboo, especially in surgery. And talking about it (or trying to get help!) can hurt your career…a very dangerous situation.  And that’s why we’re discussing it here.

 

As Surgeons We Spend A Lot Of Time Looking For Less Common Diseases…

As surgeons, we spend a lot of time and money preventing adverse events in our patients. For example, CTAs for blunt cerebrovascular injuries (BCVIs). BCVIs have a low incidence yet morbid consequences…but nowhere near the rate of physician suicide! It’s unacceptable. Let’s be scientists (& doctors!) about this and start paying attention to this problem. After all we spend a lot more time looking for things MUCH less common than depression.  Depression is treatable and many suicides are preventable. So next time you see someone who may be struggling, become their doctor and save a life. We owe it to our patients, our loved ones, ourselves to prevent the loss of more surgeons. And most importantly, we owe it to our colleagues who are suffering with depression.

The Surgeon’s Ego Has A Purpose

 

By:  The Generation Y Surgeon (@GenYSurgeon)

 

I’m Interested In The Surgeon’s Ego…

Social sciences fascinate me.  Social psychology, influence, compliance gaining, emotional intelligence, interpersonal dynamics, how to lead change…all of these topics run rampant in our workplace.  It’s no wonder why there are so many medical and hospital dramas on television.  Our workplace, including the hospital as well as pre-hospital workplaces, medical school, academic labs and private practices, abound with pathological behaviors and interactions.  Some of which are purposeful and useful, others of which are clearly not.  Stereotypes abound: the outwardly loving yet passive-aggressive pediatrician, the lifestyle-obsessed and distracted emergency department doc, the painfully awkward yet brilliant physician-scientist and my personal favorite, the egotistical, over-confident, sharp-tongued surgeon.  The surgical ego is one of my favorite subjects and I have many thoughts on how this came about as well as why it continues to exist.

(Pre-hospital staff, nurses, administrators and ancillary staff….you’re not off the hook.  I see you and your time will come–I will be writing about you as well!  This blog post however is dedicated to my fellow physicians, specifically my surgical colleagues.)

The Stereotype Of What It Is

The stereotype: inappropriately confident, stern and unwaivering, ruthlessly focused on the task at hand…and ignorant of the surrounding emotions of other people–or just not caring what they may be.  Surgeons thrive on chaos and adrenaline and they’re proud of it. 

Everyone knows surgeons have big egos.  What you may not think about is why.  I will offer this: the surgical ego has a purpose, and that purpose is to protect the surgeon.

Here’s Why It Exists…

Medicine is hard.  Doctors struggle to stand out in undergrad, struggle to succeed in medical school and struggle to remain standing upright throughout residency.  Physicians sacrifice years of their lives, putting off high incomes, personal growth and even family until they emerge as an attending.  And even then they work obscene numbers of hours in high stress positions.  Yes, the work is personally and (eventually) financially rewarding; however, the cost of getting to attending-hood is often underestimated.  

Surgeons undergo the longest and most rigorous training.  Residency teaches more than knowledge; it’s about decision-making, leadership and technical skill.  The environment is high stakes for teacher, patient and learner alike.  That’s where the surgical ego comes into play.  And the ego is shaped by the environment in which it must exist.  

IQ and emotional intelligence are often in conflict.  Pitting these against professional duties in a hospital?  Well this is where even the smartest and most socially adept doctors begin to fail.  Before we get to the pathology associated with the surgical ego, let’s talk a little more about what the most emotionally intelligent physician may look like.

Let’s Go To The Books

In Daniel Goleman’s famous book Emotional Intelligence, emotional intelligence is defined and broken down into five domains:

1. Knowing one’s emotions. This is self-awareness, the ability to monitor feelings from moment-to-moment and stand confidently behind your decisions.

2. Managing emotions.  This is resilience, the capacity to deal with how your feel and manage what comes next.  

3. Motivating oneself.  Controlling emotions for productivity, creativity, mastery and attention.  This is how you achieve the “flow” to continue with outstanding performance. 

4. Recognizing emotions in others.  In other words, empathy.  

5. Handling relationships. Popularity, leadership, interpersonal skills and mastery of labile social situations.  

Now imagine you are a trauma surgeon and you are leading the resuscitation of a young pregnant woman who was stabbed by some low-life outside the grocery store.  The patient is about to die, and so is the baby.  The injury is severe & it requires a procedure that you’ve only read about before.  The trauma bay is chaos and the staff are clearly upset about the scenario.  You can hear family members wailing outside.  What do you do?  How do you act?

Let’s Apply Our Definition

Let’s put this in the context of emotional intelligence.  After all, we just read about it above.  Think about the definition of emotional intelligence:

Know your emotions.  Easy, you’re scared, likely tachycardic, unsure of yourself and your ability.  But you cannot show it because…

You must stifle your feelings because someone’s life depends on it.  The only way you can manage is to ignore the fear and….

Motivate yourself.  You think hard and develop a game-plan for the operating room.  You quickly prioritize what must be done and there is no time for…

Other people’s emotions.  The family, the nurses, the onlookers, they are about to decompensate into puddles of tears, frantic with emotion so you…

Manage the room with firm leadership, loudly commanding the staff with clear, unwaivering words in an effort to get this patient to the operating room and save a life.

It Makes Sense, Doesn’t It? 

To the fly on the wall you are inappropriately confident, stern and unwaivering.  You are ruthlessly focused on the task at hand, ignorant of the emotions surrounding you.  You thrive on the chaos and adrenaline and you’re are proud of it.  Wait….isn’t that how we described the stereotypical egotistical surgeon at the beginning of this blog?!  Think about it. 

I’m not saying that we should excuse all of surgery’s pathologic behavior, the point is to understand why some of these behaviors exist.  To bring this back to the theme of the website, systems matter.  When a surgeon exists in an effective system that eliminates uneccessary stress and tension between staff, they are less reliant on the surgical ego for protection and productivity.  Surgeons have often grown into the surgical stereotype because they have no other choice.  Where they perceive threat or challenge they fall back on what they know and the ego defenses appear.  After all, it works in the high stress situation of the trauma bay. 

In an ineffective system, the stereotype becomes necessary and after a short while the surgeon is unable to snap out of it.  It becomes a way of life and they identify with it.  Remember, surgeons spend years to get where they are and it comes at great personal sacrifice.  Even so, there is always room for improvement.  How do we get ourselves and our colleagues to identify when the situation is different and it’s time to drop the surgical ego for a bit?

I’m NOT saying the ego is inherently bad or useless.  In fact, as we described, sometimes it’s necessary and adaptive.  The question is “how do we teach and learn when it’s time to shut it off for a while?” Surgeons are smart (but often tired) so how do we learn when the situation requires different tools and instruments?

The surgical ego is one of my favorite subjects and I have many thoughts.  There will be much more to come in future blog entries.  Until then, stay curious and stay objective.  So, what are your thoughts on it?  Let me know beneath.

 

Orientation Or Disorientation?

Orientation Or Disorientation?

 

By:  The Generation Y Surgeon (@GenYSurgeon)

 

I recently graduated and transitioned into my fellowship. As most physicians know, part of transitioning to a new hospital is enduring the necessary mandatories and introductory sessions; however, as a small percentage of a large number of incoming physicians, I was grouped with the interns for orientation. This was painful for a number of reasons.  However, what made me buck was much more subtle.

 

“It’s Our Policy”…

When I showed up for orientation on the second day, one of the admit staff at the sign-in asked me where my badge was. Understanding how painful it is to replace a hospital ID badge when you haven’t memorized your employee number, my heart sank. How could I have lost that thing already?! So I looked down to my right hip, the place where it had sat for 5 years while I operated and rounded and….it was right there. The admin proceeded to tsk-tsk and point to her left shoulder. “It’s our policy..” she snapped in a sing-sing voice. Did she just scold me as if I were a child? Keep in mind that I was in the OR until after 8pm only days prior, had packed up and moved an entire apartment and was still answering calls about patients still admitted at my residency hospital. Lets just say that the response she received was not as benign as she would’ve hoped. And then I realized she didn’t know I wasn’t an intern…

 

Show Some Respect

I usually don’t snap at administrative staff; however, this interaction really struck a nerve.  What bothered me wasn’t that particular interaction as much as knowing that woman thought it was her right to speak to me like that. She wrongly assumed I was an intern and spoke at me disrespectfully as if I weren’t a physician at all. I am always respectful of the ancillary staff in hospitals, regardless of their positions. Without the techs, transport, cleaning staff, office staff, managers and administrative staff the hospitals where we work simply wouldn’t run. I will point out, however, that without physicians the hospital would be worthless and without residents (future attending physicians) the hospital would very soon be worthless.* And as such, providers should be treated respectfully, even in their earliest years.

 

The Interns Should Be Treated Like Adults…

Had this particular woman realized that I was in fact a board eligible surgeon, not an intern, I’m positive she would not have spoken to me in that way. I’m also positive that she had spoken to every other intern in that manner because she truly thinks they are beneath her. This make me angry for interns and for physicans in general. Let’s not forget that, by the time we entered residency, many of us were nearly one quarter of a million dollars into educational debt, 4 years of schooling beyond our bachelor’s degrees and already real, really tired. By the time we enter residency we have demonstrated commitment beyond our years and devotion to a noble profession. Interns should be treated like professionals, not children, because guess what…they’ve earned it.

 

…Even Though They Don’t Act Like It Sometimes

Now back to my real-life scenario. Thoroughly irritated, I looked around and much to my dismay, the interns were acting just like I had been treated. The room reeked of immaturity and bad behavior, all the markings of a group 10 years their juniors. The orientation had been set up much like college/university orientation and the new physicians were certainly acting the role. I wonder why the interns act like that, and whether it’s universal and what exactly happened during residency that pushes most people over the hump and into maturity. Would a different environment lead to different behaviors in these residents? Would they be treated differently by the admin staff?  Maybe all twenty-somethings are like that in every field.  If so, I guess I’m not as disappointed.

 

Don’t Accept It & Help Repair It

It’s important to think about what sort of environment we first expose our residents to because this first impression may have more profound effects than we realize. There are entire bodies of literature in business and management fields which outline how to create and model professional behaviors. Outside of Medicine, this is a huge deal and yet for some reason (probably because we are too busy and too tired!) physicians have let this aspect of the workplace slip. We would all agree that we have learned by modeling our seniors and conforming to the workplace norms, but what kind of norm have we set for the interns during their orientation? Should they expect to be treated disrespectfully? Should they accept that they are considered inferior to the ancillary staff during their entire first year? No, they shouldn’t. And neither should we.

 

Evolve Or Die

You may be wondering why I’m bothering to write about this issue on a blog about business models and innovation, and I’ll remind you that healthcare is in fact a business…and we are part of it. Don’t like it?  Well, guess what, denial of what it really is just got us managed by other people.  (Thanks a lot, dinosaurs, for that one.) The question is how to effectively take care of people in the current climate of Medicine and NOT to deny its realities or hope your denial and beliefs will somehow change it.  Evolve, people, or die.

 

And This Is Part Of That Business

Part of the business is building and maintaining an environment where the physicians can feel comfortable and empowered, and in this environment respectful communication is key. Somehow we have forgotten the importance of mutual respect and effective communication and our culture has shifted to the point where our incoming physicians are treated like scum. This is not how we should be ushering our interns into the hospital.

 

Where Can You Look For More Information?

As I mentioned before, there are entire bodies of literature on how to build effective workplace environments and how to communicate effectively. One free resource that I frequently use is called MindTools. I receive regular emails which outline different aspects of personal and professional growth, culture change, and common obstacles as well as some how-to guides for improving your workplace. I will challenge you to make small changes in how you model professional behaviors to the hospital staff and your mentees. With small, individual changes hopefully we will be able to change the maladaptive cultures that plague our field.

 

Disagree?  Have a different idea?  Let me know beneath.

 

 

 

*FYI:  Although I am writing specifically about physicians and residents, in spirit I mean to include all other providers…NPs, PAs, prehospital staff, etc.

 

Why Don’t We Develop Talent In Surgery?

 

By:  The Generation Y Surgeon (@GenYSurgeon)

What We Should Do Versus What Happens Now

When it comes to raw talent, Medicine has plenty.  However, we do a poor job of cultivating the skills of the individuals who make up this profession.  Innovation is about looking from an alternative viewpoint.  It’s about finding the answer to questions others don’t realize exist, and often involves finding what no one else sees.  Innovation, after all, is evolution and we must evolve or die.  Why then don’t we make better use of the talent we already have to grow our profession and innovate our way out of our current issues?  We should encourage these doctors to lead and innovate…but Medicine does the opposite.

They Come In Diverse And They Go Out Looking The Same

Medical schools covet diversity.  Medstudents enter with varied degrees ranging from history to engineering, and bring life experiences from business, education, farming, and teaching.  Each individual has unique motivations.  Throughout the early years of training, however, they are molded into a singular species and then neatly divided into groups: surgery, medicine, subspecialty, research.  Somehow we have developed a culture that encourages students to strive for “resume builders” instead of encouraging creative paths and ideas.  Medical students all look much the same when they finally apply to residency programs.  Is that what we want?

Take research for example.  Many (maybe most) medical students do research during their schooling.  Why?  Mostly because it’s what you need to do to get a residency.  But why not encourage the engineers to build a device?  Patents are just as impressive as papers.  Students with understandings of statistics or interest in management or business could be performing quality improvement projects.  Isn’t that the ultimate research?  Yet instead of pursuing creative ventures, most students devote their nearly nonexistent free time to a research project that they care very little about because it will help them get a good residency.

Fresh Eyes Don’t Last Long And Should Be Used While They Can

I’m not saying that research isn’t good for students.  Quite the opposite for a student who is truly interested in academics and finds genuine fulfillment in the process.  For them, research is fantastic.  It’s the students who don’t love research that I’m talking about.  Some of these are the fresh voices and creative minds that we should be looking to for innovative ideas!  Medical students are special because they are still naive to the culture of medicine and they see it for what it is.  Fresh eyes don’t last long and should be leveraged for what they bring.  It doesn’t take long for the system to gobble you up and change how you see the world, so let’s make the most of their viewpoints!  We should think carefully about how we train medical students.  Let’s mold them into the kinds of physicians we ourselves want to be–creative, independent and forward thinking.

Next Time You Hear Something Unusual From A Medstudent, Entertain The Idea

Doctors find it uncomfortable to think outside the box sometimes, and our experiences can train us to be rigid in our thinking.  But next time a student or colleague offers an idea that seems a little wild, entertain it and encourage them.  Some of those ideas may become the way of the future…