Saturday, November 14, 2015

Death in Paris

This is one of those days I'll remember.

Paris was attacked today. Nearly 150 people were killed in several venues with the largest loss of life being at a small concert hall where a rock band from the U.S. was playing.

Like many who take advantage of global opportunities in college, Nohemi Gonzalez, a student at California State University, Long Beach, was in Paris studying during a semester abroad program. She died in the attacks. I can't imagine how her parents feel at this moment.

Live like everyday is your last.
It could be.


Friday, August 28, 2015

I Teach, Therefore I am

Marveled at "10 Things This Instructor Loves" by Jane Dmochowski in the Chronicle of Higher Education. She astutely notes that "affection and respect do far more to improve student behavior in the classroom than snark and irritation." I've always had a healthy respect for students as well as respected those instructors who have respected other students and me as a student. There is something powerful in the relationship between an instructor and growing health care professional student. I've been amazed at how satisfying the process of teaching is.


I too agree with Professor Dmochowski and her 10 things she loves:

1. Students.
2. Students who come to class with an open mind.
3. Students who come to my class to fulfill a requirement but decide to make the most of the experience.
4. Students who give eye contact during a lecture
5. Students who come to me when they need help.
6. Students who aren't afraid to ask questions.
7. Students who tell me not just that they enjoyed my course, but why.
8. Students who have their own ideas.
9. Students who give me unique and powerful things to say in a letter of recommendation.

10. Students who are fully engaged in the learning process.

The list highlights the important contribution the student must make to the relationship. It is a two-way relationship based on responsibilities of both parties. Students who show up with an open mind, good attitude, pay attention, ask thoughtful questions who have their own ideas are my favorite students. We don't have to love each other, but if we make it a point to like each other, and have a vested interest in the others success, the student-instructor link is a powerful one.

Monday, August 10, 2015

Another Fine Physician Award

Just received this communication from this self prestige publication.

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Dear Dr X [that's me!];

It is my pleasure to inform you that based upon your [insert social media name here] Profile, we've selected you as a Top Doctor to be spotlighted in the renowned publication, The Leading Physicians of the World.

Your candidacy was approved this week, and your prompt response is needed to ensure that only your correct professional information in published.
For accuracy purposes, please be sure to visit your personal application website to verify your biographical information at:

YOUR LEADING PHYSICIANS APPLICATION

LPW highlights and profiles the world's Top Physicians by specialty. The organization has been designed to spotlight physicians that have demonstrated success and leadership in their profession, as well as to provide an opportunity to network, collaborate and share information with other medical professionals from around the globe.

Upon your final confirmation you will join thousands of other highly accomplished physicians, and your biography will appear in The Leading Physicians of the World, where a full color page will be devoted to you, highlighting your achievements, education and offered services. Inclusion in this book is not only a tribute to your success, but it is also a valuable resource for potential patients who are looking for a Top Doctor in their area.

Best wishes for your continued success.
Warm Regards,
Director of Communications

IAHCP

P.S. Remember, there's never a charge for inclusion in The Leading Physicians of the World.

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Really? Based on my social medial profile? I am honored by anyone who raves about me, but I'm skeptical at best of any award based on what I chose to put up on any social media site. So thank you IAHCP for the honor. Instead, send me a free year supply of Starbucks Coffee and we'll call it even. OK? Rather a mocha than a full page color anything.

Friday, July 3, 2015

Happy July 4th, The Birthday of the U.S.

When, in the course of human events, it becomes necessary for one people to dissolve the political bonds which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the laws of nature and of nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness. That to secure these rights, governments are instituted among men, deriving their just powers from the consent of the governed. That whenever any form of government becomes destructive to these ends, it is the right of the people to alter or to abolish it, and to institute new government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness. Prudence, indeed, will dictate that governments long established should not be changed for light and transient causes; and accordingly all experience hath shown that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same object evinces a design to reduce them under absolute despotism, it is their right, it is their duty, to throw off such government, and to provide new guards for their future security. --

Such has been the patient sufferance of these colonies; and such is now the necessity which constrains them to alter their former systems of government. The history of the present King of Great Britain is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute tyranny over these states. To prove this, let facts be submitted to a candid world.

He has refused his assent to laws, the most wholesome and necessary for the public good.

He has forbidden his governors to pass laws of immediate and pressing importance, unless suspended in their operation till his assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other laws for the accommodation of large districts of people, unless those people would relinquish the right of representation in the legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their public records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved representative houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected; whereby the legislative powers, incapable of annihilation, have returned to the people at large for their exercise; the state remaining in the meantime exposed to all the dangers of invasion from without, and convulsions within.

He has endeavored to prevent the population of these states; for that purpose obstructing the laws for naturalization of foreigners; refusing to pass others to encourage their migration hither, and raising the conditions of new appropriations of lands.

He has obstructed the administration of justice, by refusing his assent to laws for establishing judiciary powers.

He has made judges dependent on his will alone, for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of new offices, and sent hither swarms of officers to harass our people, and eat out their substance.

He has kept among us, in times of peace, standing armies without the consent of our legislature.

He has affected to render the military independent of and superior to civil power.

He has combined with others to subject us to a jurisdiction foreign to our constitution, and unacknowledged by our laws; giving his assent to their acts of pretended legislation:

For quartering large bodies of armed troops among us:
For protecting them, by mock trial, from punishment for any murders which they should commit on the inhabitants of these states:
For cutting off our trade with all parts of the world:
For imposing taxes on us without our consent:
For depriving us in many cases, of the benefits of trial by jury:
For transporting us beyond seas to be tried for pretended offenses:
For abolishing the free system of English laws in a neighboring province, establishing therein an arbitrary government, and enlarging its boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule in these colonies:
For taking away our charters, abolishing our most valuable laws, and altering fundamentally the forms of our governments:
For suspending our own legislatures, and declaring themselves invested with power to legislate for us in all cases whatsoever.
He has abdicated government here, by declaring us out of his protection and waging war against us.

He has plundered our seas, ravaged our coasts, burned our towns, and destroyed the lives of our people.

He is at this time transporting large armies of foreign mercenaries to complete the works of death, desolation and tyranny, already begun with circumstances of cruelty and perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the head of a civilized nation.

He has constrained our fellow citizens taken captive on the high seas to bear arms against their country, to become the executioners of their friends and brethren, or to fall themselves by their hands.

He has excited domestic insurrections amongst us, and has endeavored to bring on the inhabitants of our frontiers, the merciless Indian savages, whose known rule of warfare, is undistinguished destruction of all ages, sexes and conditions.
In Jefferson's draft there is a part on slavery here

In every stage of these oppressions we have petitioned for redress in the most humble terms: our repeated petitions have been answered only by repeated injury. A prince, whose character is thus marked by every act which may define a tyrant, is unfit to be the ruler of a free people.

Nor have we been wanting in attention to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which, would inevitably interrupt our connections and correspondence. We must, therefore, acquiesce in the necessity, which denounces our separation, and hold them, as we hold the rest of mankind, enemies in war, in peace friends.

We, therefore, the representatives of the United States of America, in General Congress, assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the name, and by the authority of the good people of these colonies, solemnly publish and declare, that these united colonies are, and of right ought to be free and independent states; that they are absolved from all allegiance to the British Crown, and that all political connection between them and the state of Great Britain, is and ought to be totally dissolved; and that as free and independent states, they have full power to levy war, conclude peace, contract alliances, establish commerce, and to do all other acts and things which independent states may of right do. And for the support of this declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our lives, our fortunes and our sacred honor.

Tuesday, March 31, 2015

Aggressive Teaching

I didn't just see that did I? An older, experienced, clinical instructor made a young medical student cry. What? There is absolutely no reason for a level of teaching aggression that causes a student of medicine, in any discipline, to cry. Remember when you were a new student struggling for your existence? What an asshole!!

How did it become the norm for the bastards of medicine and surgery to rise to the top of the academic medicine food chain? I can't imagine a worse scenario than the halls of medical academia filled with attitudes, agendas, insecurities, child-like behavior, tempers, egos and gross teaching negligence. Yet here we are.

There certainly are teacher exceptions to this observation and movements forward to a new perspective, but I am dismayed by the entropy, the forward motion, making the problem worse than I can ever remember. Assholes have NO place in teaching future physicians, physician assistants, nurses and others. They rob learners of their excitement for a field that is already difficult enough to navigate. They create roadblocks to learning where none should exist.

Do your part today! Kick one of those assholes in the nuts, today!
Ok, not really, but beware and create influence where you can.

Or just become a quality, mentoring, supportive, empowering teacher of young minds.
It robs you of nothing and contributes boatloads to the future of medicine.
It may actually feel good too.

Bullying Culture of Medical School
http://well.blogs.nytimes.com/2012/08/09/the-bullying-culture-of-medical-school/

Thursday, March 19, 2015

Neglect

I often think I picked the right profession in the wrong industry. But being a clinician and U.S. medicine are intertwingled and there are no other industries to practice the craft of medicine in the U.S. It would be a tremendous thing to have a path to the practice of medicine more pure in form to the original concept without the trappings of institutionalization.

Between workload, external and imposed stress, sleep deprivation on call, self neglect and double standards that condone bullying and bad behavior...I don't know that I have much more time to avoid burnout and fall into cynicism. Although, I might be already there.

Tuesday, March 3, 2015

Instructors Prayer


Dear God, PLEASE hear my prayer. I pray that, as an instructor of young clinical minds, I never become the subject of a "what the fuck" moment. Amen.


Monday, March 2, 2015

Feedback in Medical Education

There are so many things wrong with graduate medical education from selection to the educational process itself. Working with newly graduated residency trained physicians and surgeons for many years and having been involved in the process, I see how completely dangerous the current process is. But one thing stands out as a real problem with the process - Feedback.

Clinician educators are awful at feedback to students and residents eager to learn. Diatribes of instruction and learning are lost in the incomprehensible feedback that many receive in inappropriate ways and places. It's not a skill we are born with, but learning how to provide quality feedback to students and residents is paramount to creating a learning environment that doesn't have a counterproductive effect on the learner.

1. Feedback should be private. Feedback in the midst of working events in front of the health care team of others is so damaging to young minds eager to learn. The damage, the breaking down, can easily turn the eager into the frustrated.

2. Feedback should be timely. Like spanking a dog 3 weeks after he/she has pooped on the carpet, the timing of feedback should be contemporary to a behavior, skill, attitude or belief. Instruction designers suggest within 24 hours but depending on the situation, may be sooner.

3. The learner should know that feedback is being provided. Sounds simple but feedback should be prefaced with that introduction. "I wanted to give you feedback on [such and such]".

4. The learner should be able to articulate exactly what he or she need to work on to improve a skill, attitude or belief when it is completed. Those providing feedback should give the learner time during the private feedback session to re-state the issue and formulate a learning plan for the future; the "what now".

5. Providers of feedback should be open to learning how to provide feedback from learners. Formal pathways for providing learner reaction and comments to feedback is necessary to continually improve the process. With "student" feedback, instructors need to continually ask themselves and seek information about how well they accomplish feedback and what they need to improve. Instructors need continuous self assessment as they learn to provide feedback and teach: What should I keep doing? What should I start doing? What should I stop doing?

6. Feedback should be a conversation not a mini-lecture series. Feedback in post doctoral graduate education should be a two way, professional discussion that helps to reinforce and correct. In that, the student needs to understand and be able to speak about his/her perception of the issue and process to change or learn. The conversation should include a discussion about how to move forward and what the student needs to do differently in the future.

7. Feedback should be based on concrete examples and date driven/specific actions otherwise it becomes an attack on the person (which should NEVER be the intention of feedback). Feedback is best received and most effective when it involves changeable behavior that can be achieved converting feedback from the instructor into behaviors in the learner. This must be based on something the learner can understand based on concrete examples and situations in a timely manner (see 2 above).

8. Feedback should conclude with an action plan with a conclusive agreement between learner and instructor on a plan for improvement. That plan (and agreement) should be specific to who, what where when and (most importantly) how. Consequences should be completely understood (both natural and imposed consequences). Learners need to confirm that understanding and the plan.

I shutter to think how many bright, young, positive minds have been squashed violently by feedback given wrongly, inappropriately and poorly in wrong ways and with wrong means. Graduate medical education needs to change in so, so many areas, but improving feedback from existing clinical and skill education based faculty can start now.

Yet most educators that read this or similar text will ignore it's message and continue to believe that their "style" is God-given, natural and always right. From a learner, get a clue. In many cases, nothing could be further from the truth. Providing feedback is a learned, developed skill.

Saturday, February 21, 2015

System Failures

I have no illusions about medicine and it's ability to intervene in people's lives. It is necessary for our world to have a resource to go to when the body doesn't cooperate or fails.

Yet, I am constantly reminded of the failures of the system to manage the simple tasks presented. The system has become so ruthless, inefficient, redundant, pedantic and cost ineffective and I see no way out except out.

Once again I see greater attention to money, building monumental buildings and processes than I do to people and human resources. I become more and more saddened by the system and it's results. Health is not really about symptom management.

"Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. and above all, it takes a willingness to try." - Atul Gawande

I'd throw in that it takes enlightened leadership unscathed by systems, predetermined notions and despotic cronyism. But I digress.