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.

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/

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.

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.

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.

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.

Interview with Medical Expert

Q: Doctor, I've heard that cardiovascular exercise can prolong life. Is this true?
A: Your heart only good for so many beats, and that it...don't waste on exercise. Everything wear out eventually. Speeding up heart not make you live longer; it like saying you extend life of car by driving faster. Want to live longer? Take nap.

Q: Should I cut down on meat and eat more fruits and vegetables?
A: You must grasp logistical efficiency. What does cow eat? Hay and corn. And what are these? Vegetables. So steak is nothing more than efficient mechanism of delivering vegetables to your system. Need grain? Eat chicken. Beef also good source of field grass (green leafy vegetable). And pork chop can give you 100% of recommended daily allowance of vegetable product.

Q: Should I reduce my alcohol intake?
A: No, not at all. Wine made from fruit. Brandy is distilled wine, that mean they take water out of fruity bit so you get even more of goodness that way. Beer also made of grain. Bottom up!

Q: How can I calculate my body/fat ratio?
A: Well, if you have body and you have fat, your ratio one to one. If you have two bodies, your ratio two to one, etc.

Q: What are some of the advantages of participating in a regular exercise program?
A: Can't think of single one, sorry. My philosophy is: No pain...good!

Q: Aren't fried foods bad for you?
A: YOU NOT LISTENING! Food are fried these day in vegetable oil. In fact, they permeated by it. How could getting more vegetable be bad for you?!?

Q: Will sit-ups help prevent me from getting a little soft around the middle?
A: Definitely not! When you exercise muscle, it get bigger. You should only be doing sit-up if you want bigger stomach.

Q: Is chocolate bad for me?
A: Are you crazy?!? HEL-LLO-O!! Cocoa bean! Another vegetable! It best feel-good food around!

Q: Is swimming good for your figure?
A: If swimming good for your figure, explain whale to me..

Q: Is getting in shape important for my lifestyle?
A: Hey! 'Round' a shape!


AND,
For those of you who watch what you eat, here's the final word on nutrition and health. It's a relief to know the truth after all those conflicting nutritional studies.

1. The Japanese eat very little fat, and suffer fewer heart attacks than us.
2. The Mexicans eat a lot of fat, and suffer fewer heart attacks than us.
3. The Chinese drink very little red wine, and suffer fewer heart attacks than us.
4. The Italians drink a lot of red wine, and suffer fewer heart attacks than us.
5. The Germans drink a lot of beer and eat lots of sausages and fats, and suffer fewer heart attacks than us.

CONCLUSION:
Eat and drink what you like.
Speaking English is apparently what kills you.

Competition

The story of my medical career: competition with way smart yungins

Medicine

The unknowing, leading the unwilling, despite the ranting and raving of the self serving, attending to the ungrateful.

Just another day in paradise. Deja moo!

Tunnels Found

Presidio, TX - 5 Mexican nationals were killed this morning emerging from a tunnel opening within the city of Presidio today. Police say the individuals, armed with rocket propelled grenades and automatic weapons, were confronted by two local farmers returning from the downtown market in the area of the mall. Emerging from the tunnel at the edge of the parking lot, a gun battle ensued when farmers John Smith and Bob McCall saw the men, dressed in camouflage, exit the tunnel opening.

Armed with 2 shotguns in the rifle rack of Mr. Smith's F250 Ford pick up truck, the farmers held the Mexican nationals at the tunnel exit until police arrived 4 minutes after the 911 call from Mr. McCall. Texas Highway Patrol, country deputies and city police responded with enough firepower to neutralize the invaders at the tunnel exit. All of the armed Mexican nationals were killed and no injury was sustained by the farmers or responding law enforcement officers.

During the gunfight that lasted approximately 15 minutes, the surrounding area including 2 schools and the mall were placed on secure lock down. It is apparent from the location of the tunnel as well as maps found in the possession of the Mexicans that the mall and one of the schools was to be the target of their invasion. The investigation continues to and has been turned over to the U.S. Border Patrol, Texas SBI and the FBI. 

"There is likely other tunnels to be located along the Texas-Mexican border" said Border Patrol Capt Sam Remington. The formerly unknown tunnel is confirmation that the nation of Mexico, and particularly the radicle fringe of the Mexican Anti U.S. Army (MAUSA), is likely to be a continuous concern for border citizens of the U.S. When asked for comment during his recent trip to Camp David, President Obama said he is considering sending Army and Marine troops into Mexico to flush out the MAUSA and it's tunnel system.

- Imaginary Press Release. But if you are in Israel, this scenario is your reality. Just imagine.

Surgery Leadership Lessons

Dr. Kevin J. Tracey is the president and C.E.O. of the Feinstein Institute for Medical Research of the North Shore. He spent a lot of time in operating rooms over his medical career and learned some leadership lessons from that experience:

"I've seen the best of management and the absolute worst of management.  The worst is when the team fears the leader, so when someone sees something going wrong, they're afraid to point it out. I've also seen the best. It's about clearly stating the purpose and asking people how they're doing and really listening if someone needs something different that day. If the operating team can accommodate the needs of that person without deviating from the plan, that person will be a better member of the team.

Too often I've experienced surgery teams that have little interest in the team members. It seems to be all about the surgeon, then about the patient and then everyone else…if there is time. And there usually is not. Teams are, by definition, made up of talented, qualified members and without member support and care, the team disintegrates into a dysfunctional anarchy. This is the worst of leadership where fear dominates and frustration abounds.

So has been my recent history and I am becoming more and more disgusted with the environment created by its leaders lacking leadership. It's really very simple: "accommodate the needs of [the team member] without [disrupting the plan of care for the patient]" What exactly is so difficult about that concept? Team members really don't need, want or ask for much. And why are so many surgeons being turned out of training not knowing this simple concept. 

It's not about you, really.

Just Ring the Bell!

"Why don't you just ring the bell?" - Anonymous Surgeon

He didn't really say that and tell that story did he? I may not want to work with this ego maniac any longer, but this has to be the funniest conversation I've ever been involved in. I'm speechless. But that didn't stop me from chuckling out loud.

The average United States Navy SEAL spends over a year in a series of formal training environments before being awarded Naval Special Warfare (SEAL) position.

In 2005 a 4-man SEAL team, deemed Operation Red Wing, is sent in to capture or kill a Taliban leader in Afghanistan. They were discovered soon after landing in the area and forced to fight a fierce, futile battle.  Most of the team and all of a chopper full of would be rescuers, are killed leaving a lone survivor. The lone survivor is Marcus Luttrell, Navy SEAL. One of my colleagues recently watched the movie depicting these events, “Lone Survivor”.

Because of its particularly challenging requirements to become a SEAL, many candidates begin questioning their decision to volunteer for this training and a significant number Drop (from the program) on Request (DOR). The tradition of DOR consists of dropping one's helmet liner next to a pole with a brass ship’s bell attached to it and ringing the bell three times. The training and the bell DOR event is captured and shown during the opening credits of the movie.

Now, surgery can be a difficult environment and challenging but it’s not SEAL school. And surgery is patriotic and something we do voluntarily, but it’s not SEAL school. And being a healthcare provider is challenging and giving to the community we serve, but it’s not SEAL school. There is no DOR process nor should there be. It’s a career, and a calling, but not a life or death gunfight.

So to use the “bell” ritual as representative of whether to work with someone or not in surgery is ridiculous at best. Maybe even psychotic. Individuals have nothing to prove to anyone in their medical career except to themselves and their patients. We don’t have anything to prove to other providers who for whatever reason feel they are vastly superior to everyone else around them. Sometimes excusing one’s self from the company of others is better for the team, and the patient. Really no reason to stay in that working relationship or prove anything to myself.

It’s not a matter of “sucking it up”, not "ringing the bell" and continuing to work with just anyone.  That should be reserved for firefights against the Taliban.

How to Develop the Skills to Lead and Succeed

Someone sent me a review about "Enhancing Your Executive Edge" by Kim Zoller and Kerry Preston. I'm not sure it's source but It's worth putting here in total. Some great thoughts about just the behaviors that have been plaguing our system lately.

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It would be wonderful if everyone were nice to each other and had each other's best interest at heart. But the reality is, many people are out for themselves. Sometimes it is a personality issue, and sometimes it is the way the corporate structure is set up.

[Such is the reality of medicine.]

Our goal should be "lead and succeed". To do so you have to see the big picture and realize that a leader is only a leader when there are followers.  You have to be above all the petty behaviors. Although difficult, it is critical for your future to learn how to deal with these kinds of behaviors. 

All these behaviors come from ego. While some ego is important, having an inflated ego can hurt you.

Humility

If you do not have humility, as a leader it is something you must learn. Humility allows you to keep your ego in check and makes you think before you act.

Posturing and extreme one-upmanship

Have you ever worked with people who are obsessed with competing and making themselves look good? This is the definition of posturing in a nutshell. The person is constantly asking, "Who is the better one? Who can run the race the fastest?" Keep in mind that posturing is more than being competitive with others; it is a high level of "oneupping" another person. Posturing comes from a need to win and be known for winning. It may come from insecurity or jealousy of others. This behavior does not bode well for building relationships, nor does it reflect well on the person one-upping.

Sabotage

Unfortunately, there are people who will try to sabotage what we are doing to make themselves look and feel better. Sabotage is really a form of insecurity. There are so many clients who say, "I cannot seem to get my ideas known by anyone around me except my boss." Or "My boss takes credit for everything I do." Not giving or sharing credit is the behavior of a person who is sabotaging another person. The saboteur is trying to make the other person not look as smart as or as effective as he or she really is. What people don't realize is that by making someone look good, we make ourselves look good.

Sarcasm

Some people think sarcasm is funny and do not realize how much it hurts other people's feelings. There is always a hint of truth in sarcasm, which is what makes it hurtful. If you have something to say to someone, say it. Using sarcastic comments will only harm your edge and lessen respect others have for you. Keep in mind that sarcasm may be in your partially blind area. You may know that you use sarcasm, but you may not know the ramifications of it and what other people think and feel because of your sarcasm.

Some things to consider:

• Do not put other people down to make yourself look good.
• Raise your empathy level and always keep others' feelings in mind — increase your emotional intelligence.
• You may say that there are plenty of leaders who exhibit these personality blockers, and, yes, there are. 
• Do people work because of you or in spite of you?

• If you have people who work for you, will they go the extra mile for you?
• Will they stay late?
• Will others take on an extra project just because you asked them to?
• Do not "one-up" people.
• Be collaborative.
• Listen — engagement does not mean having the best idea or best story to tell.
• Do not be the subject-matter expert on every topic.
• Do not try to one-up them — you will never win.
• Do not get off ended; it is their way of feeling important.
• Smile and say things like, "That's great," and keep the conversation going.
• Are you excited for people when they are successful?
• Do you let others take credit for work they produce even when they are not in the room
• Give people credit for their work.
• When someone else's idea is chosen over yours, congratulate him or her.
• Say nice things about other people and their work.
• Realize that when you sabotage other people's work, you will lose all respect from others.
• Take comfort in the fact that people always find out who really did the work.
• Try to include others on e-mails so that they are aware of your work.
• Do not speak badly about saboteurs. That will only hurt you—especially if they have any degree of influence.
• Try to get included in meetings where the work will be discussed.
• Speak up in meetings; do not fade into the background.
• When the saboteur tells about the work that "he" had done during a meeting, use statements like, "Yes, and what I'd like to add was that when I was working on the project, I found . . ."
• If appropriate, go to the saboteur and say, "I respect everything that you are doing. I would really like to be included in the reports so that others know what I am doing at the moment."
• Aren't you just a ray of sunshine.
• Did you take your medication today?
• Do I look like a people person?
• Not the brightest crayon in the box.
• Don't worry. I forgot your name, too!
• Nice perfume. Did you use the bottle?
• When it involves trying to get a laugh at someone else's expense, it is sarcasm — do not take part in it.
• If you have said something sarcastic, immediately apologize.
• When you have said something sarcastic to someone in front of other people, apologize publicly.
• Even if people tell you that your sarcasm is not hurtful, do not believe them. They are not sarcastic and do not want to hurt your feelings.
• Stop doing it and learn some real jokes if you are trying to be funny.
• Do not laugh when they make the joke; your laughter tells them it is all right to keep doing it.
• In private, say to them, "I know you may not realize it, but when you make those sarcastic jokes, they are hurtful. I know you would not want to hurt anyone's feelings, and so I wanted to let you know.  If you are comfortable, say to them, "That's not really funny."

I hope one or more of my esteemed colleagues reads my blog. But I bet ego won't let them.

FDIC - Frightening Disseminated Intravascular Coagulation

DIC is a paradoxical event in any patient, particularly in pregnancy. Disseminated (everywhere in the body), Intravascular (in the blood vessels), Coagulation (clotting).

 DIC It is one of the most dangerous conditions that we encounter in the mother/baby realm during pregnancy and can threaten both mother and fetus. It is an extremely paradoxical event; A ballet between clotting and bleeding; Between life and death.

 A "trigger" stimulates activation of the clotting cascade and clotting throughout the body. This activation results in widespread thrombosis (clots). All this clotting leads to depletion of the raw materials of the clot...platelets and coagulation factors. The end result of this process is bleeding into many areas and organs and, ultimately, multi organ failure including fetal demise. In most cases in the pregnant patient, this demands emergency c-section with long, exhaustive NICU stays for the babies who survive.

In a word, frightening.

DIC Cascade

I've Nothing Together

"Pride will keep you from growing, because when you pretend that you’ve got it all together, you won’t make an effort to become more spiritually mature. No one has it all together! Humility leads to happiness because it makes you teachable. - Rick Warren

I've been really observant sensitive to the lack of humility in some clinicians that make them unteachable and, worse, dangerous. There is a disturbing trend I've noticed that people are genuinely unhappy in the medical centers I've worked lately. There is so much stress, whirlwind activity and demand of time. I hear so much grumbling through the day (and night) from otherwise nice people.

 The exception to the "nice" rule is the clinician who comes believing that they have it all together and that nobody else does. The lack of teachability, compassion for the team that makes them look good and general sense of untouchability is a dangerous recipe. When those below are unwilling or unable to speak their minds, patient safety suffers tremendously. But more importantly, it unnecessarily creates an environment that nobody feels comfortable in, including the patient.

 Medical education and administration has lost the ability to breed into and maintain a sense of humility in providers. The system is so broken, so lost. There is absolutely no recovery from a system that allows such behaviors to continue and, in many case, flourish. I, on the other hand, become more humbled by witnessing such aberrant behaviors and know for a fact, I don't have anything "together".

Stop the Bullies

"You suck!" That's what he said. I've certainly had good days and off days, but this was a mostly innocuous event in surgery that had no ramification to the success or failure of the procedure. It was a hand movement that provoked it. A totally over the top comment on a minor event. Did he think it would make be better?

I've really become sensitive to bad behavior in medicine today. I'm really tired of how we treat each other in the hospital and the effect it has on morale, work productivity and potentially, patient safety and care. 

"He comes to the operating room late, greets no one, and berates the nurse for not setting up the stepstools the way he likes. He tells the [assistant] he doesn’t know the anatomy and sighs when she adjusts her grip on a surgical tool. He slaps the hand of the [surgical tech] when she reaches for the retractor to pull back skin for a clearer view. The operating room is [quiet and] tense for hours."

There is a profound disrespect that abounds in the medical setting, particularly where new or student providers are present. The bullying culture of medicine is well, well known. If you haven't experienced mistreatment, you've seen it regularly. There becomes a subculture of talk about the "crazy" surgeon, who you like and don't like to work with, and the effects of such behavior on colleagues and staff.

"For the most part, I’ve been pleasantly surprised. The majority of doctors, nurses, and other health care professionals I’ve worked with have been courteous and respectful: strong teachers and compassionate caregivers. I have met colleagues whom I would feel honored to work alongside in the future and mentors whom I’d want to treat my own family should they become ill."

 But the mood and atmosphere created by the bellyaching, angry, terse talking surgeon is at least demoralizing to a surgical team. At worst, dangerous to patient care.  The psychological effect of being called out affect our state of mind in "small but cumulative ways. This is the stuff that creates a culture." And I must say that after these many years, I don't like the culture.

So I've learned to deal with the daily mistreatment. It seems to be the way it goes and has to be done. I've done the blow off explanation of that's "how he (or she) is" or "he's having a bad day" or "his mother is in the hospital". I've bonded with other staff over these incidents ('looks like you need a hug") and had conversations of "solidarity" with staff and colleagues about it. Worst, I've trained myself to ignore it, take it, swallow it, and (hopefully) get over it.

I often wonder thought what we aren't doing, what we miss and what we do in error from the effects of the fear and trepidation created in such environments. I think we rush to do things "more" right, more quickly and more expertly when we are chastised and often to the neglect of good procedure that really shouldn't be rushed. Is the environment created by these bullies making people so nervous that they can't really do their job correctly? I think so. And unfortunately I've seen evidence of that recently in the OR.

I can't remember a time in medicine when cooperation, respect, and relationship among colleagues and staff was more important. It takes a team to make medicine happen, particularly in surgery.

"Now, enter the culture of disrespect. Suppose an attending physician makes withering critiques or unreasonable requests. A resident, hoping to avoid such abuse, slowly but surely starts to hold back. She holds back some questions for fear of burdening and, under the constant stress of being scolded, becomes immersed in details of efficiency."

"A substantial body of data attributes medical errors to interactions among hospital workers. Calls for improved patient safety gained traction from the late 1980s through the early ’90s, when Australian researchers reported a shocking find: the vast majority of medical errors, some 70‑80 per cent, are related to interactions within the health care team." If that is the case, then bullies create environments that have the potential to create error.

"The link between harsh words and medical errors was reignited in 2012 when Lucian Leape, professor of health policy at the Harvard School of Pub­lic Health, published a two-part series in Academic Medicine. ‘A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect,’ Leape and his co-authors asserted. ‘Disrespect is a threat to patient safety because it inhibits collegiality and co-operation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.’"

"When anger and intimidation flow down, information stops flowing up. The chain of communication becomes clogged."  Some of the most popular reasons for lac of communication in the hospital setting, according to research: Intimidation. Fear of confrontation. Concerns about retaliation.

"When someone is unpleasant or demeaning, something switches in the minds of those on the receiving end: they sacrifice honest communication to save face. I’ve seen it in action so many times that the pattern has become predictable. Preoccupied with fear of appearing incompetent, team members keep uncertainties under wraps."

"Many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence". I am experiencing such a shameful experience now. No new competence comes from harsh, disrespectful communication.  "Brutality doesn’t make better doctors; it just makes crankier doctors. And shame doesn’t foster improvement; it fosters more mistakes and more near-misses. We know now that clinicians working in a culture of blame and punishment report their errors less often, pointing to fear of repercussion. Meanwhile, when blame is abolished, reporting of all types of errors increases."

"Bad cultures lead to bad outcomes. Jerks do not make good medicine. They foster a backwards atmosphere that degrades trust, tarnishes open communication, and promotes cover-ups."

I wish I knew how to stop disruptive behavior. But likely if I speak out about it, I'll be dismissed so that the disruptive surgeon bringing in financial benefit to the hospital can continue to rant and rave. Thus facilitating the behavior it hopes to eliminate.

"We can’t ignore a system that takes loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones" I yearn for a hospital culture that shames bullying making the bully look like the bad guy, rather than making the recipient look weak. 

There is not quick fix, but I for one, am beat up enough for a lifetime. And I don't think I'm a better provider for it. Maybe I just suck.

Time Flies

Time flies when you are having fun or busy putting people back together again. It's no excuse, but writing superflous wordage about next to nothing take back seat to patient care. Now I know how all the King's men felt. It's been a busy time with leaving internship and going to work.

It's been a great learning experience on many fronts. I don't think like a medicine people and being back in surgery is wonderful. Those who can't memorize, operate.

 Quote of the past few months: "Can you imagine what a great surgeon I would be if I could find help who were as good as me?" - Anonymous, M.D.

I continue to strive. Per chance to dream.

Gossip

A man approached Socrates one day to share some gossip. The wise philosopher asked, 'First, are you certain it's true? Second, is it something good? Third, is it something useful?' When the man said, 'Not really,' Socrates replied, 'Well, if it's not true, good or useful, why talk about it?' Gossip can feel like a form of intimacy, but it's actually a false bond motivated by the desire to diminish another person and make yourself look good.

There's WAY too much gossip in the hospital. Much is not useful. But some can be. How do we know?

The following questions can help you decide if it's useful talk:

Are you telling someone who can do something about the problem by helping, or offering discipline or correction?

Are you talking to someone wise enough to help you process your feelings and courageous enough to make you do the right thing by confronting the other person, or confessing where you're at fault?

Is this news approved for sharing?

Are you breaking a confidence, and if so, is it strictly because the person is endangering someone's life, including their own?

Are you willing to divulge your source so it can be checked?

When you say this, does it break your heart?

Would you be comfortable if someone was saying this about you?

Asking...

Bad Behavior

Ilana Yurkiewjcz, a Harvard third-year medical student, writes eloquently about something that has bothered me in medical education for years... Bullying.

She writes about a minority of staff and clinicians across all ranks of staff who are profoundly impactful and are outright bullies.

What is interested me most is her description of those subtle "micro aggressions", subtle putdowns, shaming interactions, sarcasm, passive-aggressive and frankly bad behavior.

There was something very relieving with reading her article. It read like a summary of my resume. Beyond her frank observations is the course reality to what may be wrong, at least in part, with the educational system of physicians and other healthcare clinicians today. Sometimes I'm so ashamed to be associated with this world.

http://aeon.co/magazine/being-human/why-rude-doctors-make-bad-doctors/

How many people does it take

A little while ago I helped deliver twins in an emergency C-section situation. The babies were way early, way small and unfortunately they had to be delivered right away... "Stat", on steroids.

This scene is absolutely chaotic. Or rather sort of an organized chaos. At one point I counted 16 people in the room with various roles and responsibilities. There is the scrub team which includes a surgeon, an assistant, and a surgical tech. There is a respiratory support team for each of the twins. There is an anesthesia team which includes a physician and a nurse anesthetist. Then there is the pediatric and neonatal resuscitation team from pediatrics and neonatal intensive care. Then there is a charge nurse for the operating room and patient care assistants to assist all of the team members.

It truly begins as a rather chaotic scene with all the members of the team scurrying around the room preparing for the delivery. But once the timeout is complete and the scalpel hits the skin it is truly poetry in motion. I don't believe there is any more skilled team in healthcare today then those that deal with high-risk births. It is truly a pleasure and a blessing to be a small part of the effort.