Where Everybody Knows Your Name

It is the classic refrain in the surgeon’s lounge. Whenever you ask a fellow surgeon how their day is going they are either waiting to start a case or waiting on turnover. I used to remember going into a day of surgery with a sense of excitement. I was going to “heal with cold steel” ( but now mainly with the robot). And while I continue to really enjoy caring for my patients surgically, my mind is also occupied by what barriers are going to be placed in my way today that I am going to have to overcome to provide this care. Is it not having an anesthesiologist to start a case on time, a lack of adequate staffing, unfamiliar staff, equipment issues- the list can be pretty long.

My clinic can sometimes be just as frustrating. Because I practice at more than one site, the differences can be striking. In one location, I have a very consistent group of medical assistants, nurses, and clerical staff. In the other location, my nurse is my lifeline but it is rare that I know the medical assistant by name because of attrition and reassignment. I really value the idea of a team and this compounds the frustration around my care.

Like many organizations, our health system is trying to contain costs for a variety of reasons. I get it and support it. The biggest bang for your buck as an administrator is controlling staffing. Personnel is our biggest expense and not filling positions can be a way to make budget. The need for margin is crucial as academic health systems see research and other dollars drying up that needs to be reconciled on the back of the clinical mission. So decreasing staff through attrition is a easy way to decrease the cost per unit of service in administrative language.

This is often spun in a way that we are trying to reduce waste in the system. The other target tends to be supply costs. Especially in the OR, disposable costs can make the difference between case margin or not so surgeons are asked to standardize care by picking one vendor, decreasing the use of more expensive supplies, and being thoughtful about using certain items.

Again, this is a good thing- we want to decrease cost and improve our value proposition. These cost containment strategies and efforts have a natural ebb and flow. The thought is given competition, the ability to grow is not infinite given the limited supply of patients. So in order to improve margin to support our missions, we all need to chip in to cut costs. But from the ground level, I definitely don’t see a decline in patients. With the countervailing efforts to improve patient access, I see more and more patients who need my clinical and surgical care and much of the discussion in the surgeons’ lounge revolves around how busy we all are.

There are several frustrating factors about these cost containment measures. First, they are reactionary. They are a response to external pressures from board members or leadership to achieve short term goals. When the pressure is off, rather than continuing the efforts to decrease waste, things tend to back slide. If we are truly trying to improve value by containing costs, then it should be a continuous effort and not dependent on short term goals.

But more frustrating is the fact that cost containment seems to occur with broad brush strokes. Organizations tend to expect all segments to reduce costs equally rather than take a surgical approach ( no pun intended) to cutting costs. Of course, it is a much harder and politically fraught task to consider which areas can be cut more than others. We tend not to like to pick winners and losers but sometimes there are opportunities to eliminate entire programs that are not working and reinvest in areas that are either higher margin or that provide more meaning to the patients we serve. While academic health systems must provide comprehensive care, there is no shame in differentiating investing in winners and containing costs in low margin areas to help the organization succeed in its missions.

There are two big buckets of waste that often get ignored but hold tremendous opportunity to both improve value and tackle burnout amongst all those who care for patients. Recently, I was talking to one of my colleagues in the surgeons lounge. He had come from private practice and was used to being very productive. When he came here, he tried to maintain that level of productivity but soon found himself in the OR late at night to the point where his family was suffering. He was then discouraged by administration from adding on cases not because of his quality of life but because of overtime costs related to staffing later in the day. His productivity for a normal 12 hour OR day was cut by about 30%.

In my mind, that is waste. If there is a differential between what can normally be accomplished but the system creates inefficiencies causing a reduction in productivity, that is clearly waste. Add up this wasted physician time amongst all the surgeons in a health system and we are talking about millions of dollars that overshadows any other cost reduction strategy that is currently in place.

While the return on investment is huge, the roadblocks to improving efficiency within a finite time period and not overburdening the clinicians and staff is a tall order. It requires developing processes that support the work of the clinician. Administrators cringe because they immediately believe this requires the investment of more resources and while modest resource investment sometimes is necessary, the greatest opportunity is to create stable teams that understand the work and can collaborate in real time to continuously improve processes and improve efficiency.

Again, managing this is difficult. Flexible staffing models allow cross-coverage that can deal with the daily staffing issues that arise but this type of team approach does not have to be for everyone. At least in the OR, my guess is that 20% of the surgeons do 80% of the surgeries. That may be an exaggeration but it is relatively easy to determine who are the busiest 10-20 surgeons in an organization. If you could trial a true team based approach that spans the episode of care for patients even in a small fraction of these busy surgeons, then you could measure three variables to see if the reallocation of resources result in a return in investment. First, does this model increase the productivity per unit of time. This is obviously a step function since decreasing the time to accomplish a set number of cases does not decrease waste in a model where staff are paid a set salary and not by time. Second, does this model improve staff and physician satisfaction and quality of life? I will discuss this more below. Finally, does this model improve the value proposition for patients? Are outcomes better? Is patient satisfaction improved? Is cost stable to improved because the team does not use extra supplies because they are knowledgeable of the care being delivered?

The second area of waste that also intersects with the second metric above is staff turnover. Some data suggests that turnover rates in hospitals are approximately 20% per year with the average cost averaged out amongst all staffing categories of $60,000 per lost employee. That is a staggering number if you consider a larger health system and a real area of opportunity.

Now people leave for a variety of reasons- career advancement, to be closer to home, family reasons, dissatisfaction, benefits, hours and the list goes on and on. I have been frustrated over the years by HR practices that prevent me from helping to retain good employees. While a discussion of reducing turnover is beyond my expertise, I do believe that creating stable cohesive teams can both improve efficiency and satisfaction amongst everyone on the team helping health systems reduce cost and improve value.

If given the opportunity, I would take another approach to containing cost that values time and people. Stability of staff beats saving money through attrition. Waste in the OR often occurs when unfamiliar teams are working together. Sure SOPs can be useful, but they don’t beat a team that knows exactly what is and is not needed for a surgery. They can also continuously improve both outcomes and reduce waste that can’t be done by a static process by inconsistent teams. I would trial this approach with a few surgeons or busy clinicians and empower people locally to make decisions that support better patient care and efficiency rather than some centralized process developed by those who do not know the work. Money spent on more oversight, project managers, outside consultants, and expansion of administrative overhead could be reallocated to those caring for patients. Metrics like those above can provide accountability coupled with PDCA cycles to improve on care delivered rather than resourcing the squeakiest wheels in the organization.

These efforts would go a long way to improving both costs and satisfaction amongst every employee grouping who cares for patients. In the immortal lyrics of the 80s sitcom Cheers, ” Sometimes you want to go where everybody knows your name; And there always glad you came; You wanna be where you can see; Troubles are all the same; You wanna be where everybody knows your name.”

Thanks for reading.

Don’t Hate The Player or The Game

A few years ago, I did some alumni interviews for my alma mater. If you have not had the pleasure, I highly recommend the experience. You get the opportunity to meet some of the best and brightest high school students in your area applying for college. In addition, as a parent of kids that I hope are soon college bound, it gives you some insight into what makes a compelling applicant.

But, of course, there is a dark side to this process. By reviewing the CVs and personal statements beforehand, I could see who had been coached to be able to check off all the boxes that a computer algorithm would approve of and those kids who lacked this additional support. I guess that is why many of these colleges still go through the trouble of actually interviewing applicants because while a system can be gamed, a human being may identify the massaging of the CV more readily.

I’m not saying that human beings can’t be fooled (think Russian hacking of the election) but someone like me with a bit of healthy skepticism and a comfort with asking lots of questions stands a better chance of separating the wheat from the chaff.

I chose to meet at a local coffee shop for most of my interviews because I hoped the neutral environment would put the students at ease and the parents, if they wanted to, could be present at a safe distance. I recall interviewing a young man from a good school in town with a tremendous CV. Good grades, good scores, two varsity sports, volunteer activity, and membership/leadership in at least 8 different clubs and associations. While impressive on the surface, it seemed too good to be true.

I started off easy. The grades and standardized test scores are hard to fudge (although not impossible as the college scandals have taught us). Of course, there was tutoring and paid test prep involved. Then I moved on to sports. The swimming was real- it was clear that he cared about it but his other sport was clearly for off season purposes and he was a bench warmer at best. I then went in for the final strike and randomly picked the finance club where the facade started to break down. At first he put up a good show- he was Vice President of the club after all. Turns out the club had three people, had met once a year ago, and had really done nothing except register for official recognition from the school. I gave him a chance to recover by asking him to pick an extra curricular that he was more passionate about and the rest of the house of cards crumbled.

I thanked him for his time and as he was leaving the store, I got snippets of their conversation- he felt positive. Clearly lack of insight.

I had set up two interviews that day and my next person was a quite young lady who came by herself from one of the public schools in town. Her grades were also good as well as her test scores. Her personal statement was solid but her CV was very different. Instead of pages of many clubs and volunteer experience, she had 4 things. First, she worked at her parents restaurant every Friday and Saturday night. She went to church every Sunday and volunteered for Meals on Wheels after church. She played flute in the orchestra which had been to All State every year she was on it. And while she did not participate in a sport at school, she had completed two marathons and continued to train 4 times per week. She talked about everything in such detail that I knew this was not trying to game the system.

As you might suspect, I gave my second interview a very high recommendation for admission while the first interview I was very neutral. Both would be successful at my alma mater but I felt the second applicant was much more genuine and would take advantage of the opportunities the school had to offer over just being able to put the name of the school on their CV.

I promise, here comes the punchline. Whether it is getting into college, medical or graduate school, landing the next big position, or any number of competitive endeavors we participate in as humans, there is a game involved where we try to gain an advantage over others in the process. We can talk as much as we want about how things should be fair and based on merit but that is what people say when they have lost the game. But that does not mean that we have to accept this system as the status quo. In fact, the more we accept this state of affairs, the more ineffective we become as a culture at actually solving problems or getting anything done.

But just like AA, admitting that there is a game that must be played is the first step. I was offering some career advice to a mentee recently. We were at a meeting surrounded by senior experts in the field and I asked him to tell me what each one was known for. This is in no way a criticism of any of these people because I am in the same boat ( although clearly less successful). These folks are Chairs of Department’s, Division Chief’s, full tenured professor’s at their institution, national/international thought leaders. Most folks, however, are built off one or two themes. However, if you dig deeper, most of these leaders in the field have 100s of publications of which only a tiny percentage have any impact on the way we practice or how patients are cared for. But that doesn’t stop people from leveraging these publications in the game for academic promotion, national prominence, speaking engagements, grants, or any number aspects of the game.

My advice to my mentee was not that this was bad, but that this was the model to emulate to be successful in this game. In general, most people create a story around their work that may or may not be impactful and leverage this for grants, career advancement, etc… However, I also encouraged him to remember what was part of the game and what really matters.

The interesting part of academic medicine is that what gets you recognized and promoted is not necessarily what is meaningful about our work. I acknowledge that some of our ranks do some very meaningful research that does impact the way we practice and the patients we care for. But impactful research often spans years or decades and is sometimes not finished in one person’s lifetime. Meaningful discovery and innovation often build on sometimes disparate elements of many peoples’ work. It is rare that there is a discovery that one person alone can take the credit for. People who truly aim to make an impact in the area of discovery must toil for years and deal with setbacks and frustrations and continue to persevere.

We can’t equate that kind of work with 100 or even a 1000 publications and while an individual publication might have some influence on practice, its impact is often fleeting. Again, it does not mean that it is not of value but the value has to be put into context.

The real meaning of our work comes from the daily care we provide patients and the learners we educate who go on to care for others. This type of work is compensated but not valued in the same way by an academic institution. Sure, there are some of us who make their career on new surgical innovation and technology. But this is an arms race and unless you constantly adapt to the newest technology, you can be quickly left behind in that game. And, honestly, this matters very little to patients. At the end of the day, they care little about the size of their incision or the number of ports used and more about the safety, outcomes, and competence of their surgeon. I’m a minimally invasive surgeon and believe in what I do but the surgeon and judgement matters much more than the tools used.

What I worry about is that either we don’t acknowledge there is a game or that we have come to equate the game as meaningful in its own right. This leads to the elevation of people to positions of leadership that are good at spin but lack the fundamental skills and integrity to meet the obligations of that role. Worse still, is those who have been part of the game for so long are constantly looking for the next move rather than committing to the work that must be done in their current position.

This disconnect between the gamesmanship required to achieve elevation and the actual skills and integrity required to serve as a leader are eroding not only academic medicine but other civil institutions in our society. We have equated fame and notoriety with capability. We have come to equate capability with Twitter, Instagram, or YouTube followers. Again the game has always been there but the danger is that it has elevated people into positions of authority that lack the skills to be effective and that impacts everyone. The best way to judge how capable someone will be in a future role is to look at their past performance, not at the number of publications or likes on social media.

That is the reason why I picked a part the CV of my first applicant. If he had stuck to what was real, he would have been just as successful as he was without the padding of his CV. The game is starting earlier and earlier and it is everyone’s job to teach our kids to recognize the game for what it is and help them understand that real worth and meaning is not equal to how well someone plays the game but rather how well we execute on what is expected of us and how we meaningfully contribute to the world around us. I don’t usually bring my religion into these blogs but there is a concept in Judaism that sums up what I am trying to say better than anything I can write: Tikun Olam. Simply put, our obligation as individuals is to try and leave the world a better place than when we arrived. Let’s not fool ourselves that the game benefits anyone else but our own selves. We can do better and I hope we teach those around us to separate the game from true meaning. Thanks for reading.

Physician As Journeyman

Like many other physicians, I am continuing to struggle with our future in the evolving healthcare field in the United States. I know that I have talked about physician burnout before and we have all been inundated by both commentary and scholarly discussions on the cause of burnout amongst physicians and what to do about it. I think it’s safe to say that none of us have a good answer.

Several recent blogs I have read seem to point to the idea that we are working too hard and there are not enough of us to meet the demands of the aging population. A natural solution, like many skilled trades is to unionize. This certainly has its advantages in terms of collective bargaining for certain minimum rights and to counteract the ever increasing regulatory burden that we all suffer with individually.

But there are several major flaws to the idea that physicians as a group should unionize. First, for many specialties, we do not have a shortage. What we have is a distribution problem. For example, the density of urologists in Michigan is relatively high in Southeast Michigan which includes Metro Detroit. However, go North of Lansing and we have sparse urologic coverage especially when you get to the upper peninsula. I see a lot of people for high level urologic oncology care from across the State but most urologic problems should not require a 6-12 hour round trip car ride to address. I suspect that outside of primary care specialties, mental health, and pediatric specialties, distribution and not supply are the issue.

And this naturally flows into my second point. Physicians are not a single monolithic group. What drives burnout and frustration in one group is entirely different than in another specialty. Hospitalists, ER physicians, Anesthesiologists, Radiologists, and Pathologists have different drivers from each other that markedly differ from surgeons, OB/GYN, and primary care physicians. Hence unionizing by health system or hospital which would make sense from a bargaining standpoint may be challenging because of the varied needs of different specialties.

Finally, there are legal and logistic challenges. Are we able to unionize? What is the law around this? And even if we do choose to unionize, right to work laws don’t require a physician in a hospital to be part of the union. Also, who do we bargain with- the hospital, the health system, the payers? For many surgeons, our interests are aligned with the hospital we operate out of and care for patients post-operatively and in many rural hospital, their margin is very tight so extracting better compensation or benefits may win the battle but lose the war.

An obvious solution is to try to turn back the clock where most physicians were in partnerships and many current large single specialty groups promote this as a way for physicians to extricate from the mess we are in. There are many problems with this model that are equally troublesome to the employed model that most of us find ourselves in currently. First, there is a need for critical mass to provide leverage for these groups with payers and health systems. While some large groups are attempting to franchise themselves across State lines to smaller practices often in partnership with venture capital, this cannot cover every group. There has to be a positive ROI for this to make sense to the big group. Communities are less concerned with ROIs and more concerned with care but doing the right thing is often not the driver of the equation when investors and shareholders are involved. Ultimately, the bigger problem is whether you are part of the mothership or the franchise, you are still employed by someone who expects productivity, margin, and adherence to regulations and metrics to cover the same types of overhead that health systems must cover. Sure, the practice supports ancillary income streams that support the bottom line but does not solve any of the other issues that are factors in burnout.

There is a third way that could help some physicians and address the lack of access to healthcare in rural areas. But to describe it, I have to pick up a few historical threads.

Kidney and bladder stones have burdened humanity throughout much of recorded history. The first descriptions of cutting for stone come from ancient Egypt and Hippocrates called out this care specifically beseeching physicians to leave this work to specialists. As such, a group of surgeons known as lithotomists arose to fill this need. They would travel from town to town cutting for bladder and urethral stones through the perineum or suprapubically. Outcomes were often poor and while specialized instruments and techniques were developed, the practice was barbaric due to the lack of anesthetic and often failure to appreciate the anatomy. For patients that did survive, they often lived with fistulas that left them debilitated.

However, the concept of itinerant surgeon traveling to meet the needs of patients rather than patients traveling especially for common disease processes makes sense. A patient really should not have to leave their locally community hospital to have a kidney stone treated or safely have their bladder drained when they are in retention or stabilize someone with gross hematuria. But for many patients, sometimes there is no other option but to travel to receive care.

While rural or underserved health systems try to recruit surgeons often at great expense, when they do find them, they often cannot keep them. Initial income guarantees are unsustainable, there is often no connection to the community to encourage someone to settle down, and being on a island leads to professional stress and isolation. I personally take lots of calls from solo urologists bouncing cases off of me where they know the right answer but just need to discuss with a colleague for confirmation. We take these interactions for granted in our big groups. Locums is the epitome of the itinerant doctor and solves the problems created by trying to recruit a permant clinicians but leads to lack of continuity of care and sometimes lack of quality control. In addition, this constant cycle is costly to patients and health systems.

Yet the idea can be modified and there are historical models that can be used to guide us. Guilds developed in medieval Europe as a way to ensure that certain skilled trades met certain standards. Traditionally, an apprentice would train with a master craftsman for seven years. Sure, it was not great-their pay was often in the form of room or board and they were essentially indentured to their mentor during that time. Eventually, however, these apprentices would graduate to journeymen who were employed and paid. They would work for a master craftsman but could leave and find other employment if they chose. While many never rose to Master craftsman, there was the opportunity to do so based on the rules of the particular guild.

Many journeymen would travel to work with different masters for three years before settling down. This allowed them to hone their skills and also carry new ways of doing things to other areas.

If this sounds familiar, that was the intention. Internship and residency mirrors apprenticeship while fellowship and many doctors’ first positions approximate the journeyman role. Lastly, established clinicians and academic faculty serve as master craftsman that keep the system afloat and transfer knowledge and expertise.

What if we could take pieces of the traveling specialist and the guild model of apprentice, journeyman, and master craftsman and create a model that would serve the needs of our patients and help fight some of the aspects of burnout that are afflicting practicing clinicians?

I still believe that one of the greatest factors in burnout is lack of autonomy for physicians. But I have been toying with another model that I call the Law of Addition without Subtraction. While physicians are the most skilled and highest paid employees of a health system, our time is not truly valued. More work gets piled on our plates and nothing is ever removed even if what we are doing no longer makes sense. The cutting and pasting of labs and other results into notes that are present in the electronic medical record and (un)meaningful use are two simple examples. But what about mandatory learning modules taken year after year or the countless mounds of emails and metrics we are exposed to? We need a system for physicians that values our time through appropriate compensation and decreased burden, meets the needs of patients, and battles burnout.

Instead of unionizing, different specialties should form guilds. You may argue that we have this already but national specialty societies are too removed and unfocused to serve the needs of their members. Regional or State specialty societies don’t seem to serve this role either. Guilds could be formed on a number of levels- a county, town, or logical region depending on the density of clinicians and the needs of the area. These guilds could then negotiate to provide services to underserved hospitals at an agreed on market rate that would appropriately compensate and support the clinician but free the doctor from billing issues. In exchange, these guilds would guarantee quality and ensure physicians are practicing to current standards. One way that this would fight burnout is that physicians could choose to take blocks of time off and still be compensated. The guild would ensure coverage and continuity of care. Some physicians could remain journeymen their whole career working part of the year and spending the rest of the time with family or pursuing other meaningful activities while others might choose to make a position permanent and graduate to a master craftsman getting the periodic support from a traveling journeyman. Fundamentally, this model could help re-establish the autonomy that many of us feel we have lost while serving the needs of patients and communities.

The cynic out there will say that this model cuts out the locums companies as middlemen but there are several distinct differences. First, a guild would establish quality standards for admission and ensure that members maintain this to remain in the guild. This self-policing strategy brings autonomy back to the clinician. Second, it creates a sustainable coverage model for underserved communities that locums cannot. A contract with a guild would guarantee service even when the covering physician gets sick because those in the guild who are not working at that time could cover. There are credentialing, privileging, and licensure issues to this type of coverage but potentially if a guild could attest to certain standards and outcomes, these processes could be shortened.

Ultimately, even if you do not like this idea, our current system is not sustainable for anyone. Burnout is taking our best clinicians out or leading them to become disengaged in change. Decisions are increasingly being driven by overly bureaucratic organizations based on metrics and margin statements without contemplating the physical and emotional toll on physicians, nurses, other clinicians, staff, and most importantly patients. The good will model of relying on the sense of obligation of professional to do more with less with the failed promise of improved efficiency through technology or process is running the ship to ground. Something has to change and a guild model might work for certain segments of physicians.


Be Excellent to Each Other

My inspiration can come from anywhere which is true of many people who enjoy writing. I’m constantly on the alert for the little snippets in my environment that can connect the dots between sometimes disparate thoughts. Surprisingly, inspiration struck on a Sunday afternoon in a most unusual way (pun intended).

My 12-year-old daughter and I were sitting on the couch trying to find something we could both watch after a busy day filled with many scheduled activities. I really value this unstructured time and while it could be spent more productively, there is a human need to “veg out” and let the mind idle. My kids have gotten in the habit of asking me to find “old” movies to watch. They seem to enjoy the less than stellar effects, odd looking clothes (i.e Member’s Only jackets and parachute pants), and strange phrases uttered by people of my generation. There are of course, the modern classics which I believe most would say were worth having their kids watch- Indiana Jones, Back to the Future, ET, Ghostbusters, Spaceballs, Top Gun, Beetlejuice. Of course, the appropriateness level is variable. I thought Big would be appropriate but it definitely had some sexual themes I did not remember. No surprise that my kids enjoyed The Princess Bride but UHF? My son asked to watch it a second time (and since then has been watching Weird Al Yancovic videos).

So it was in this vein that my daughter asked me to dig deep and find her a classic we could watch together. As I wracked my brain, it suddenly came to me- Bill and Ted’s Excellent Adventure.

If you do not remember this cinematic masterpiece, you are not alone. Starring Keanu Reeves as Ted and Alex Winter as Bill, this story takes place in late 80s San Dimas, CA where the fate of future intergalactic harmony depends on these two friends passing high school World History. With intervention from a future time traveler (Rufus-George Carlin), Bill and Ted collect historic figures ( Socrates (who they call Sokrates), Billy the Kid, Lincoln, Napoleon, Freud, Genghis Khan, etc…) to help in their final presentation.

This movie is not an intellectual juggernaut and while we enjoyed watching it for how bad it was, on the surface it would not seem inspiring. But then, it clicked.  Like I mentioned, I have these random thoughts and it sometimes takes a simple phrase or image to make it gel. A few weeks ago, I operated on a very nice lady. Because some of our patients come from far away, I often schedule surgery for patients by talking to them on the phone first, getting their images and records, communicating with the local doctor, and meeting them in clinic the day before surgery. Often these patients have their surgery and I follow-up by phone or video visit and they have their surveillance with the local physician. It saves patients from having to make costly and time consuming trips back and forth to Ann Arbor as well as reducing the stress that many have from being away from home and family.

After the surgery, I saw my patient the next day. She was up walking in the halls and ready to go home. I walked the hall with her and all of a sudden, she gives me a big hug out of the blue. She mentioned that before I called her, she was scared, had not understood what the other doctors had told her, and was afraid she was going to die. She thanked me for talking to her like a human being and for how kind everyone else had been to her and her husband.

When I get thanked for doing my job, I of course am gracious but I’m also sad inside. Explaining medical issues to patients who see us in ways that everyone can understand is our job. I unfortunately see too many patients who come to us for second opinions just to get some answers. I don’t blame the other doctors. Explanation takes time and too many of us have too little time to spend with our patients.  But when it comes to surgery, even if a patient is willing to trust me with life and limb, I’m going to confirm that they understand what the plan is and can articulate it back to me. Shared knowledge builds trust and demonstrates respect for our patients. In my patients case, just a little extra time transformed a harrowing experience into positive medical care.

The other thought that watching the movie pulled together for me is the idea that small talk helps us connect with someone else on a personal level.  I have taken care of many of my patients for years and I always try to take a minute or two to ask them about their family, their hobbies, or something else that is meaningful in their life.  Conversely, my patients have become comfortable asking me non-medical questions.  They want to know how my kids and wife are doing, whether I have taken time off, how was my last fishing trip, or how my administrative role is going.  I know that there is no time for chit chat and my patients know that others are waiting to see me but I believe these short exchanges accomplish two important goals.  First, and most important, is that this innocuous exchange of minor details acknowledges the humanity of each of us in the room.  We are not just doctor and patient but real people with multidimensional lives that exist outside the exam room.  Second, it helps me and the patient to see the person beyond the disease.  I care for mostly cancer patients and I am always trying to encourage people to live full lives even while they are receiving treatment so that they know they are not the disease but rather a valued mother, father, friend, neighbor, etc… who has life beyond treatment.

Small talk and simple conversation can really help people out in their darkest hour.  I was in the cafeteria buying lunch.  Behind me was an older man who looked completely out of his element.  I was going to let it fly but as he was trying to pay for his food, the tray tipped on the floor dumping out his lunch.  Me and another person quickly re-ordered his food and helped him bring it upstairs to his wife.  It turns out as we were chatting that we were both from the same town.  I grew up in San Antonio and its a big city and where I grew up was no where near his home but that simple connection gave him some grounding.  You see, he was up visiting his wife’s family and she unfortunately got ill and needed to be hospitalized.  He was far from home without his kids and scared what was happening with his wife of 43 years.  His wife did get better and through that simple exchange, I was able to find her a specialist for her condition in San Antonio who had been in my medical school class.

We talk about kindness and compassion to one another but I believe that Bill and Ted aimed for something higher, “Be Excellent to Each Other”.  Being excellent to each other implies something greater than kindness.  I sometimes feel that when we are kind or do good deeds, we are doing it more for ourselves than the person we are trying to help.  We are trying to prove our worth or find meaning through action.  But being excellent to one another implies that we are being kind, compassionate or helpful with no strings attached and that the interaction is really providing meaning to both parties.  It is about finding joy just by being with someone else, conversation without an agenda, or mutual activity that is not about competition or goals.  It is about valuing those around us for who they are rather than who they are not and breaking down the multitude of barriers that keep people apart.  Ultimately its about treating everyone we encounter with dignity and respect and accepting the same from others.

The one thing that struck me about the movie was Ted’s behavior.  Despite the threat of military school in Alaska, the demeaning language that his Dad would assail him with, Ted always responded respectfully.  Bill and Ted may be idiots but their approach to life was not stupid.  I don’t believe it is hard to start being excellent to each other.  Instead of paying attention to our phones in the check out line at the grocery store, engage in small talk with those around you.  If they don’t respond, no big deal.  But eventually a person might and you might learn something you never knew, find a connection that would have never been revealed, or be in a position to help someone else or for them to help you.  There does not need to be an agenda.  I know this borders on the creepy in the “#MeToo” era but perhaps simple non-threatening conversation without an agenda is a way for us to restore the web of humanity that we need in our lives.

While Bill would always say, “Be excellent to each other”, Ted would respond “Party on, dudes.”  While life is not a constant party and we all deal with stress, tragedy, and pain, being excellent to each other forges connections that allow us to find joy in the small things in life.  With the increased rhetoric of divide and difference being spread by both ends of the political spectrum in our society, we need to be excellent to each other more than ever now to restore sanity to our culture.  I hope you will join me in being excellent to those around you.

Thanks for reading.

We Are All Aging Physicians

Last week, I was watching the second of the televised Democratic presidential candidate debates with my father-in-law. The exchange between Congressman Swalwell and Vice President Biden generated a good conversation between me and my father-in-law. I was somewhat disappointed by the cheap jab made by Swalwell at Biden but it did raise the important question of when experience and wisdom cross over into decline that could create challenges and even danger in a demanding job like President of the United States.

In fact several of the top tier candidates as well as our current President are 70 years old and above. It’s hard work being the leader of the free world and national or international disasters that require urgent attention do not keep “banker’s hours”. Conversely, youth which does come with energy and new ideas (“rookie smarts) also has its drawbacks. We are all continuous learners in the school of life and those accumulated experiences help us tackle current and future challenges that a more youthful person may never have encountered. Mentorship can help address some of those gaps but in a job like President of the United States, the ultimate decision must be made by the person who was elected to that office or risk undermining the integrity of the position.

There is of course, no easy answer to this question and ultimately it will be up to voters to decide how young is too young or how old is too old to be the leader of the free world. However, this issue did hit close to home.

Many organizations are struggling with how to manage aging physicians. While the electronic medical record forced many doctors into early retirement, the current demographics of physicians approximate that of the general population and there are plenty of doctors who are still practicing well into their 70s and occasional 80s. I don’t need to go into too much detail here because a number of media organizations have written on this subject. Yet despite public awareness and acknowledgement by both health systems and professional organizations, this issue has been difficult to address.

Like President, experience means something no matter what type of specialty we practice. Sure, there is an added dimension of physical ability for surgeons and proceduralists but often the medical decision making prior to an intervention influences outcomes more than the technical aspects. And experience can often outweigh slight technical declines. The role of surgical volume on outcomes is well established. The ability through experience to anticipate problems and avoid or mitigate them wins out over the technical ability to correct an error when it happens.

But aging has its drawbacks and medicine can be physically and mentally demanding. Long days, being woken up in the middle of the night on call, medical conditions and medications can impact anyone’s ability to perform but for a doctor, these can become life or death factors for a patient.

We have an adequate mechanism by which young doctors gain expertise and experience. Sure the process is long- medical school followed by residency training and often fellowship. This often can occupy a decade of a young person’s life. Of course, safeguards remain in place once a doctor completes their training in many circumstances. While there is much to criticize about specialty boards, they do create some type of baseline that physicians must cross in terms of medical knowledge to be recognized by their specialty. And formally or informally, most practices do have focused professional practice evaluation (FPPE) for new colleagues that often includes case review, assisting with care or surgeries, and tracking of outcomes. I was supported in this way when I completed my fellowship by my senior partners and I continue to do the same now after 12 years with my new partners assisting them with surgeries, reviewing cases, and helping them hone their skills and expertise. They get my accumulated experience and I, in return, get exposed to new ideas and techniques that prevent me from becoming a dinosaur.

But we are failing on the other side of the spectrum. As an Associate Chief of Staff for my Health System, I am called upon to lead peer reviews when faculty are found to have quality or behavioral gaps that impact patient care. These cases escalate to us from Departments when local processes are not working, from staff or other colleagues that raise concern, from patients, or from internal and external reports of patient risk.

While not all of these involve older physicians, my sense is that we are in the midst of period where we are going to be forced to develop a systematic approach to help physicians more as they evolve through their career. In truth, we are all aging physicians and if we could develop a just and kind solution to a problem that currently creates distress to colleagues who have dedicated their lives to caring for others, it would help all of us in the future.  It’s easy to say that we’ll know when to stop practicing but the reality is that many of us continue to practice beyond our shelf life because we don’t know a better way to spend our time, have continue financial commitments that prevent us from retiring, or simply still find joy in what we do.  Because of these factors, it is incumbent upon all of us to develop a pathway that can be used as people enter the later part of their career.

This challenge is not only due to demographics and aging. In fact, I believe a major contributor is related to the increased expectations for performance (RVUs) and the associated scrutiny that comes with expecting all of us to increase our clinical activity.  Couple this with the era of increased metrics and data and we have created a recipe for disaster for our more senior colleagues.  It’s funny because I used to see medicine as a pyramid scheme.  Senior partners or faculty could slow down and still accumulate a healthy income while new hires and junior members of the group would “hump” it indirectly paying for their more senior partners.  This worked only if those at the bottom of the food chain were able to make their way to the top.  All that is gone now and while it might seem fair to expect everyone to pull their weight and cover their salary, it has left us with the unintended consequence of expecting senior faculty and partners to function at a pace that they are no longer used to maintain their income.  This risks patient harm and quality concerns.   Ongoing professional practice evaluation (OPPE) is, of course, designed to spot outliers and trends in physician practice. The problem is that often the data we collect has a greater emphasis on process which is easier to collect than actual outcomes that matter to us and our patients. When we get a real outlier signal, it is likely that we are already too late in protecting our colleagues from error and patients from harm. We need to be able to see the signal in real-time and react before it’s too late.

Another cause of the current aging physician challenge is a change in culture. Increased transparency is leading patients to expect better outcomes and health systems are responding by focusing on safety and quality. Whether in the form of process improvement, high reliability, or another management tool, those who deliver health care are being held to a higher standards. This has the effect of breaking down the “old guard” mentality that might protect a physician of inferior quality or dwindling function from scrutiny. No longer can someone slide by with bad outcomes just because they have been at an institution “forever” or the Dean, CEO, or other health system leader thinks they’re a good “guy” because their kids went to school together or they socialize outside of work.  While this cultural shift is long overdue, it again comes with secondary consequences that some of our senior colleagues are not equipped to handle.  Judging someone’s career on today’s standards lacks nuance and risks devaluing the many contributions of a person that made our current care possible.

Current solutions have been met with resistance. Some health systems have tried to implement cognitive and medical evaluations starting at a particular age. Identifying a medical or mental health issue that can be improved is a critical part of peer review and providing our colleagues with respect and due process. For example if someone has sleep apnea and a CPAP helps with their memory and function, then this allows someone to continue practice. Additionally, identifying substance abuse or disability gives us a chance to return a colleague to well being.

The problem is that current efforts and tools are imperfect. Neuro-psych testing often fails to identify a problem in a doctor who performs better than the standard population even if there is decline. In addition, standard medical evaluation is not sophisticated enough to reliably isolate impairment that can impact performance. While more robust evaluation tools exist for physicians, these are often very costly, require specific expertise and as such can not be used  as a tool for all aging physicians.

The biggest barrier to the recognition of decline is often the physician themself. Often, doctors come to the attention of health systems due to a lack of insight into how they are physically/mentally changing and how that impacts their performance. Instead, they choose to see themselves as their best selves when they were at the top of their game even if that was 20 years ago.

But data is hard to ignore and we are fortunate to live in an era where data could give us a proactive mechanism to help provide guidance as we all age in our careers. This might have more of a slant toward surgeons or proceduralists but I believe that with some minor adjustments, it could be applied to doctors of any specialty.

First, we can use administrative data such as Commercial or public claims data to compare an individual physician to their colleagues. In particular, for surgeons, looking at volume, readmission, and morbidity/mortality could be used to help a surgeon with insight into their own practice compared to others. We are fortunate at Michigan Medicine because we participate in a number of continuous quality improvement collaboratives with Blue Cross Blue Shield of Michigan that provide real time data on outcomes that are fed back, adjusted and compared to peers. While the intention is for improvement, this data could also be used to identify gradual decline which could be used to adjust an individuals practice before quality or safety are compromised.

In addition, other data can be used to help identify a career roadmap as a physician in a particular specialty ages. While recertification and MOC have become dirty words, most specialties require case logs be submitted to allow someone to sit for a recertification exam. These logs could be reviewed and aggregated harnessing the “wisdom of the crowds” to understand what cases are being performed and at what volume in someone’s 1st, 2nd, and 3rd decades of practice. Sure it would need to be adjusted by subspecialty and other practice factors but the data could provide individual guidance about when to stop particular aspects of a practice. Similarly, many specialty societies now collect census data on their members and this could add granularity to when certain procedures fade out of a clinicians practice. It can also offer insight into what other peers start to do as they evolve in their career ( more office based procedures, for example). Together, these sources of data could be used to help a physician as they consider how to evolve their career over its lifetime.

Of course, this concept would need to be tested to understand its value but it presents the aging physician ( which is all of us) with a mix of objective data and peer comparison that would be hard to ignore even for those who lack the insight to know when to stop doing certain things. While more difficult to implement for more cognitive specialties, even starting with surgeons could help our colleagues maintain dignity throughout their career and protect patients.

Using age alone to determine fitness for duty is discrimination whether someone is running for President or caring for patients. While voters can decide the issue of the age for our highest office, we can’t put everyone’s retirement up for a vote. The ability to evolve in our careers, shift focus from more physically/mentally demanding tasks to other non-direct clinical activities and more straightforward clinical activities means that we can be useful for sometimes longer than in other careers. However, our personal interest and ego must never supersede the interests of our patients and thoughtful application of existing data can help.

The Hyper-Specialization Cliff

I remember my first day of clinical rotations like it was yesterday. I had my fresh short white coat, my gently used stethoscope, an eye card, my reflex hammer, a pharmacopoeia, and the handy survival guide for clinical rotations that our medical school provided. I felt ready. I was going to heal people.

I learned very quickly that a lot of care for patients admitted to the medical service at a county hospital had very little to do with healing. It was more about mitigation, addressing social issues, dealing with the lack of a medical or societal safety net for some of our most vulnerable community members.

As an a medical student, we each had to pick up 4 patients on call. We would obtain the medical history, perform the physical exam, often draw our own labs, wheel patients down for x-rays (we could not get a CT or ultrasound at night and MRIs were rare as hen’s teeth), perform our own EKGs (and try to interpret them), and most importantly, formulate a differential and plan.

If you had a good senior resident, then they gently led you in the correct direction. If not, then after morning rounds with the resident team, me and my fellow medical students would head to the library where we would pour over Harrison’s or another medical reference trying to find answers.

I new my calling was not internal medicine when after presenting my first patient to the attending where I reviewed the diagnosis and plan for a patient we admitted with diabetic ketoacidosis, he asked for my differential diagnosis. I stood there confused. We had “the” diagnosis so talking about other possibilities seemed like a waste of time to me when we had 19 additional patients to see followed by hours of work to implement the plan.

My senior resident chimed in with a brief summary of what we discussed last night and we were able to move on. The pace of rounds frustrated me and I was more interested in solving problems and doing procedures than perseverating on obscure causes of the common diseases we were caring for.

As I progressed in medical school, my path took me further and further away from this tradition of considering differential diagnosis based on physical exam, laboratory, and imaging findings to more technical aspects of the care we deliver. I gravitated toward surgery first which I enjoyed. However, general surgery did not appeal to me because I felt they were jacks of all trades and masters of none. Hence I delved into the surgical specialties and found my home in Urology.

After finishing medical school, I had two years of surgery to contend with before being able to devote my efforts to urology alone. It is during those two years that I truly learned how to care for sick people and I often thought back to those Medicine rounds wishing I had learned how to read EKGs better, that my physical exam skills were better, and that I could come up with a longer differential diagnosis than three possibilities especially when those three didn’t hit the mark. I rotated in the cardiac and surgical ICUs where often I was the only doctor at night having been told by senior residents to “call me if you need me but need me if you call me.”

The most striking example of where I truly needed to be a doctor first and a surgeon second was in the ER. We did not have an ER residency when I began my training and as a second year resident, I was responsible for evaluating all the patients triaged to the surgical side along with my intern. Sure, we could call the ER attending but they were often overwhelmed on the medical side. Night after night, I would have to try and figure out the potential causes of a person’s abdominal pain. Often, they were not surgical but once triaged to surgery, they were my patient to try and come up with a disposition.

After I survived my time in general surgery, I was able to focus on Urology. However, Urology is a surprisingly broad field where we care for a variety of problems from kidney stones to cancer, metabolic disorders to incontinence, children, women, men, and elderly patients. Despite enjoying the variety, I still craved technical mastery and chose to specialize in oncology and minimally invasive surgery. I completed my fellowship and have been an academic Urologist for almost 13 years specializing in kidney, bladder, and testis cancer. I still manage common urologic problems on call and see a fair number of patients with hematuria and elevated PSA in my clinic but my practice is focused on a narrow group of patients and heavily emphasizes surgical care.

Why am I telling you all of this? My experience is very similar to many specialists and even many “generalists” wind up developing a niche over time. The reason I am writing about this is that I believe that our excessive specialization in medicine is creating harm for both our patients and for our profession. Let me break it down.

On the surface, specialization offers patients the opportunity to see a doctor who has laser-focused expertise in their problem. This should result in better outcomes for the patient and for many complex surgeries, there is data that supports that a surgeon with high surgical volumes produces better results than a lower volume clinician. This assumes that a patient has a diagnosis but when they don’t, a patient must often go from one doctor to another to try and find answers. Sometimes the dots get connected but the more common scenario is that the specialist is only able to rule out that the patient does not have the problem that they treat. Even when the doctor possesses the skill to dig deeper, they often do not have the time required to think about the differential diagnosis and complete the necessary problem solving that goes into less common disease identification. This is the time when a patient needs Dr. House and they are nowhere to be found.

The bigger problem for patients is that specialization limits access to care. For example, in an academic medical center, physicians often limit their practice to a small number of diagnoses based on their clinical and research interests. This leaves patients with some diagnoses on a long list waiting to be seen potentially leading to delay in diagnosis and care. I often tell my colleagues that while most of us are sub-specialized, except for pediatric and pelvic floor urology, there is no specialty board and that all of us should be able to function as general urologists. Even our colleagues in community practice are specialized through a process of elimination based on interest and resources and often patients are forced to seek care outside of their local community incurring additional costs to help manage their disease.

More insidious is the attitude that some clinicians develop based on their specialization. They approach their patients’ medical care with a hammer and every disease they see is the nail they treat calling into question the appropriateness of a patients’ care.

And while these are huge problems especially when access to care is a major problem for many Americans, this hyper-specialization is hurting us as doctors as well. Our training programs are perpetuating a model of sub-specialization that may not be preparing our trainees to go out and meet the needs of the patients they are expected to care for. In the best of circumstances, these doctors have partners that can help them or a referral center nearby to help them solve problems for their patients. In the worst of cases, though doctors without a safety net feel put out on a limb potentially leading to bad outcomes.

In these cases, patients often seek answers to their medical problems outside of conventional medical care. Sometimes these can work but they are just as likely to be ineffective, costly, and potentially delay definitive care. Overall, this weakens the role of doctors in communities leading to frustration on both ends.

Perhaps the greatest problem for physicians of this super-specialization is the psychological distress it can create. We want to be able to help the people that come to us for help. They sometimes have problems that we should be able to fix but we lack the general knowledge to do so. Our sub-specialization is likely a source of burnout as it has made us overly reliant on systems resources which narrow our autonomy and take us further away from serving patients which is what has brought us to medicine in the first place.

There is a third aspect to hyper-specialization which impacts us all as a society. Because many doctors know only a small slice of medical care, we have become overly reliant on referral to deal with care that we should be able to manage. For example, I learned how to work up chest pain and evaluate cardiac fitness for surgery as an intern and resident. I could still easily order a stress test on a patient with a cardiac history prior to surgery but I also know that the anesthesiologist will want clearance from a cardiologist prior to surgery. So I make a referral to a cardiologist. Many of our consults are wasteful not only because we can do the necessary work-up but also because they sap time away from the doctor seeing the referral to provide more complex care. This adds cost without a tangible benefit. There are many examples where either we refer for convenience or because of health system norms that do not serve the needs of our patients.

Hyper-specialization also leaves potential gaps in care for communities that cannot attract a specialist or do not have the volume to support the specialty practice. This is a huge problem for rural communities that are increasingly losing hospitals that cannot remain solvent due to a lack of medical staff that can help care for a population and maintain a bottom line.

We can solve this problem and both help ourselves and our patients. Taking a page from medical systems of other countries, we could require medical graduates to serve time as general physicians in underserved communities. This would help alleviate issues of access to care. It would also allow new graduates to continue to expand their general medical knowledge. These new doctors could continue to receive educational support from their medical schools through didactic training and access to faculty for advice and expertise. This service could be compensated through salary and by paying off part or all of a new doctors loans. The money to make this happen could come from both insurers and hospitals who would see cost savings by allowing patients to continue care in the lower cost setting of the community or offsetting the need to seek emergency room or higher level care through improved access. Thus, the opportunity cost for a young doctor would be mitigated and they would continue to gain valuable experience to improve the care they deliver in the future. It would also help re-establish the vital relationship between doctors and a community.

For practicing physicians , solving this problem is more complex. However, there are things that we can all do to help us increase our relevance to more patients. First, continuing to take call keeps most of us connected to our broader specialty. The trend toward paying doctors for emergency and consult call appropriately acknowledges the time and effort required to do this work but it has allowed some physicians who are busy with their clinical practice to recede from the life of the community. Rather, some call expectation should be linked to clinical privileges at a hospital as was the common practice in the past but as support for this effort, physicians should receive loan repayment. Even though I am a specialist, I take call at a community hospital where I operate and also cover call at one of our affiliated hospitals a few times a year. Sure, I get paid for it but I also benefit from being able to continue to practice general urology and reduce the overall burden of call for my colleagues who primarily practice at these sites.

While there is no going back to the day where a local community doctor delivered a baby, performed an appendectomy, and provided for all of their patients needs, I believe our current system has gone too far and we need to find a way to reconnect with why we started on our medical journey- to care for people. I believe we benefit both our communities and ourselves by walking back from the hyper-specialization cliff.

Happiness Is Not the Goal

I will admit that I have been having a mild middle life crisis for the past 6 months.  I can’t really point to what brought it on but thoughts of my purpose and path forward have been weighing on my mind more than usual.  I tried to shake it off as a “first world problem” but that rationalization ignores the very real impact that these thoughts have on my emotional wellbeing.

It’s funny how several external sources can converge over a short period of time to help make sense of the world when you need it most.  These are not the typical sources of guidance and inspiration but they have really helped me and I would like to share what they are and how they have helped.

I may have mentioned this before but I have always had a soft spot for the underdog story.  I love stories and ideas where people overcome adversity to find meaning, happiness, and success.  I was having a quiet moment on a Sunday afternoon with my wife when we watched an episode of Street Food on Netflix.  If you have not seen this, it creates a beautiful picture of the street food of a particular Asian city through the use of sharp cinematography, great story telling, and interviews often highlighting one individual “street vendor”.  The first episode we watched was in Bangkok and featured Jay Fai, who became a street vendor out of necessity to feed her family but progressed to a point where she was recognized with a Michelin star.  Restaurants much loftier strive to achieve this rating but very few do.  However, Jay Fai did not achieve this by setting it as a goal.  She achieved it because she focused on making excellent food one dish at a time.  Her goal was not external validation but to be better than she was the day before and to achieve perfection in every dish.  It is in the process of creation and the sense of satisfaction she received from the people who ate her food that she found meaning.

It is interesting that much of the other episodes follow the same formula and while I do not think the intention of the series was to identify an archetype of a successful street food vendor, I do believe that is what it achieved.  Forward progress was driven by necessity but long term satisfaction was derived from finding meaning in what was being made and the community that they built around their business.

My second source of perspective is more conventional.  A few months ago, I was listening to NPR and they were interviewing Thomas Friedman on his new book, The Road to Character.  I’m still grappling with whether I agree with the fundamental premise of this book but the argument he makes is that we have transitioned from a “Little Me” to a “Big Me” culture.  Our current society emphasizes that we are the master of our own destiny, to trust our instincts, and that if we strive and work hard enough we can achieve the happiness and success that we were meant to have.  Our previous culture emphasized that we are part of something bigger than ourselves, that our instincts should be treated with caution to avoid falling prey to our inner demons, and that ultimate “success” was not necessarily happiness but finding meaning within ourselves and the context of our community.

On the one hand, his arguments really appeal to me.  Most people, I believe, come to realize that chasing success, fame, fortune, and external validation do not lead to happiness.  It is an appetite that can never fully be satiated.  It is shallow and ephemeral.  Instead, finding meaning within oneself and understanding yourself in the context of something bigger whether it is G-d, your community, an organization or a cause you really believe in leads to long term meaning that withstands the “slings and arrows of outrageous fortune”.  Where I struggle with Friedman’s argument is the idea that to achieve this one has to give themselves over completely and shed the modern persona of achievement.  Our street vendors could not give themselves completely to their craft if they could not survive doing so.  If no one would eat the food they made, they would have to find another occupation to subsist.  While they might find true meaning in making food, it is only through their connection with the community that this meaning is realized.

In addition, his argument takes a particular religious angle that does not align with my world view.  Many of the examples in his book cast off their worldly endeavors to serve a Christian ideal of G-d and “the golden rule”.  But someone could equally find meaning by giving their heart over to Satan or a cult leader.  I worry that this inner search to find meaning leads many to the right place but some to a very bad place.  For others, this acceptance of a greater meaning is used to absolve individuals of their sins when some mistakes can’t be easily washed away.

My religious world view is that my upbringing has provided me a sense of right and wrong.  As I try to teach my children, the rules are simple- work hard at what you are doing, be truthful, honor commitments, and treat others with the kindness and respect you would hope for yourself.  Hence, there is a general sense of right and wrong that represent universal truths in the world that come from our heritage/culture/religion and it is up to us, as individuals with free will to choose to live by these rules.  Thus it is impossible to find meaning in life without accountability to our own selves first and those around us.  This is where I think Friedman’s argument falters.

Together, these two sources have taught me two things despite their flaws. First, true meaning in life is understanding our flaws whether they are failings of character or action and trying to improve everyday. I’ve never told this story but the event that continues to be my greatest source of regret and flaw that I continue to work on to this day occurred when I was 16 years old. My mom was being treated for breast cancer and I was supposed to pick her up after her treatment and I forgot. I forgot my own mom. What kind of son does that? This was in an era of no cell phones. When I did get home I found 6 messages on the answering machine and when I finally drove to pick up my mom over 3 hours after I was supposed to, I found her waiting up front with the nurse with the rest of the lights off in the building.

She got into the car without saying a word. She didn’t need to. It’s funny because I doubt my mom even remembers this but despite this happening over 30 years ago, it is something that pops up in my mind quite often and has defined a major part of my moral framework. Since that time I have always tried to honor my commitments, be honest in my interactions, and sometimes unrealistically, demand the same from others. It has sometimes lead me to view the world in very black and white terms which has created some rigidity in my relationships.

I continue to work on being true to my word and honoring my commitments. Every failure hurts my inner being and makes me yearn to be better. Of course the second lesson learned is that individual meaning cannot be achieved on our own. Sure, individual efforts can lead to individual success- more wealth, fancier titles, easier life. But individual meaning comes from being part of a community. That does not mean that we are subservient to the group or that our efforts must be for the benefit of the greater good. It means that our search for meaning in life is placed in a greater context. Serial killers have not achieve true meaning in their life because their actions are contrary to community moral compass. Our individual search for meaning depends on us being part of something greater than ourselves.

I don’t want to come off as a moral ogre but I have come to appreciate that happiness is not the goal and striving for more titles or money or whatever will not provide me happiness. Happiness is not bad but it is fleeting, a mere moment of time, and a life of meaning is not built on moments. My last source of inspiration drives this home. In the HBO documentary Chernobyl what struck me most was not the great tragedy that unfolded. Sure it was awful beyond imagination. The two points that struck me was a leadership culture of blame and denial where leaders protected their self interest by throwing others under the bus or ignoring vital information from inferiors. The most striking point, however, was the sacrifice of the thousands and thousands of people who helped mitigate the crisis despite knowing that they were sentenced to death from radiation exposure. The leader of the miners characterized it best. His group was brought to tunnel underneath the reactor to place a cooling unit. Their work avoided radiation contamination for 40 million people by preventing water contamination. When asked if the state would take care of the miners, the leaders offered no commitments and despite this, they continued their work. They did the work they knew in service to each other and the broader society not for reward or glory but out of necessity.

My journey is not over but I feel that focusing on meaning over success will help me find peace with myself. Maybe our world would be a better place if we spent less time on transient happiness that on long term meaning. Thanks.

Grand Central Station

Maybe my patience is getting shorter as I get older but I have felt that the number of distractions in the operating room has increased dramatically.  I know this is a well researched topic and as I was contemplating what I would write about I had a chance to review PUBMED as well as several other sites including several well written statements from the American College of Surgeons.  However, in my review of these sources, I found that the real world implications of this distracting environment were lacking.  Sure, we all know that every time someone enters or exits the room the positive pressure can be overcome allowing the “dirty environment” from the hall to enter the room increasing the risk of infection for the patient we are trying to help.  We also know that our smart phones provide distractions to those in the operating room in multiple ways.  However, I would like to argue that the problem is much greater than this and as a surgeon who cares both about the patient and the entire surgical team, it is time that we all speak up in the interest of better outcomes and patient care.

I’d like to break this topic into three segments.  First, I will try to describe the elements of the distracting environment from the ground level.  Second, I will review the problems with distractions.  Third, I will discuss what we can all do about this.

Distractions in the OR can be broken down into two categories.  The first is related to the movement of people.  The second is the encroachment of the external environment into the OR environment.  When I walked into the OR for my first case earlier this week, I found a total of 14 people in the room including me and the patient.  Of course, many of these people are necessary to help with the surgery but I think we can all agree that 14 is too many.  In addition to me, the patient, the anesthesiologist, and my resident, the other people in the room were the nurse anesthetist (needed when the anesthesiologist goes to another room), an EMT student there to practice intubation, the circulating nurse, the scrub technician and her scrub student, our surgical PA, the robotic technician, and a monitor who comes in randomly to see if we are performing the pre-induction and pre-incision checklist correctly.  Finally, there were two medical students in the room- one rotating on Urology and the other on anesthesiology.

While this was a larger operating room, many of our operating room spaces are small and this many people make a crowd.  I am very supportive of our need to teach but as the surgeon who the patient came to with their cancer, it is my duty to balance this teaching obligation with my number one priority of patient care.  Even in the best of circumstances where we have a large number of people working together on a regular basis, this large a group requires leadership and management to direct activities.  In normal circumstances, I have not routinely worked with everyone in the room and worrying about who is doing what and whether they are capable of doing what they are supposed to be doing is a huge distraction from my primary job which is to perform a safe and effective operation.

The other challenge with this many people is that as a surgeon who cherishes my role as a teacher, there is only so much bandwidth I can contribute to teaching on any single operation.  If I am performing a robotic surgery and have a relatively new PA assisting at the bedside as well as a resident or fellow who is sitting on the other console wanting to learn and a medical student who is asking questions to learn about the surgery, disease process, and natural history of the cancer, how do I divide that time?  I have enough experience and expertise to be able to confidently teach while I am operating but even the best teachers struggle between transitioning to different learners with different needs at the same time.  Its akin to trying to teach at an old one room schoolhouse with multiple grade levels while performing a skilled trade all at the same time.  To manage this, I compartmentalize my efforts so that I try to give everyone the attention they need but not at the same time.  Sometimes, one group must be ignored out of necessity if teaching one particular person is necessary to help progress the surgery.

Of course, this complexity is only the tip of the iceberg.  The second big component of distraction related to people is the constant intrusions into the room from various people for various reasons.  This is perhaps the best studied aspect of distraction in the operation room with the metric of door openings as the key outcome measure for any study.  What these studies don’t often get into is the reason for why a person is opening the door and what the implications are for the surgery.  On first pass, the most logical reason to leave or enter the room is to obtain additional supplies or equipment needed for the surgery.  In my informal review over the last several weeks, tmost common reason is actually one staff member giving a break for another staff member.  There are many people in the OR space that get routine breaks to have lunch, get a drink of water, etc… as mandated by law and/or institutional policy.  This includes the circulating nurse, the scrub tech, and the anesthesia team.  I don’t begrudge people breaks but there is often no apparent pattern to me as to when breaks are given.  It did not seem to matter how long the case was as to whether someone got a break.  It did not really matter when during the case someone was given a break (although scrubs that I regularly work with will pass on a break at critical parts of the surgery).  It feels like breaks seem to escalate as the day progresses and it is not unusual for me to have a different anesthesia team, scrub, and circulator for every case after 3 PM which is when shift change occurs at our institution.

The door openings are only a minor distraction compared to not knowing who the circulator or scrub is in your room at any given time.  A key component of the surgical checklist is that everyone introduces themselves by name at the beginning of the surgery.  This is supposed to create familiarity and a sense of team because it is easier to communicate with a person who’s name you know rather than calling them circulator or anesthesia.  The current process makes this a moot point because I have to look up, ask the person’s name, and then ask for what I need when someone is being subbed out every 15 to 30 minutes.  Those few seconds can disrupt the cadence of the case.  And forget about me but this churn distracts everyone in the room from the work that needs to be done.  The perfect consequence of this occurs on a very long case when the people who I started the surgery with are long gone and the replacements had variable sign out resulting in incorrect needle, sponge, or instrument counts resulting in the need for unnecessary x-rays and added time under anesthesia.

I don’t want to belabor the point but the number of reasons people come in and out of an operating room are mindboggling.  Good reasons include bringing in supplies or medication or picking up surgical specimens.  In addition, I often will check on my colleagues in other rooms before or after a surgery to see if they need any help or if I can do anything like check on their inpatients to help reduce their distraction in the OR.  But often we have charge nurses walking in to see how long a surgery may last, other people coming in to discuss non-patient related issues with a colleague.  In this environment, the patient and what we are here to accomplish becomes an afterthought to some team members.

The second culprit of distraction is the external environment encroaching into the OR.  Again, this is a topic that has been well studied and characterized.  There are so many ways that things in the OR encroach on our attention.  Pagers, electronic white boards, smart phones, other monitors and instruments with alerts, the electronic medical record, internet access, music, and probably 10 other things I have not described that bring in external pressures on the attention of the surgeon and surgical team.  Some of these are of course necessary.  Our integrated electronic medical record allows real-time access to the patient’s medical record as well as being able to instantly call-up and display imaging studies.  This is a huge improvement to when I first started and everything was still paper charts and imaging studies that had to be displayed on light boxes.  But just like Times Square, almost everywhere you look in the operating room is occupied by visual and auditory distractions.  The decision to play music in the operating room has been studied with inconclusive results but I find that it helps because it provides a “white noise” that helps dampen other noises and the beat can often help with the cadence of a case (I will ask the circulator to change the music if it is particularly slow).

Many have transitioned to smart phones for medical communication but it is often difficult to discern whether an alert on the phone is a page, text communication, or an alert from an app that I or any of the other myriad people in the room forgot to turn off.  We can’t shut our phones off because even though we must be focused on the patient we are taking care of, on call responsibilities, calls from clinic, or other urgent matters sometimes do require temporary distraction to assist with the care of another patient.  The bigger issue is how much technology can pull our attention away from the patient and task at hand.  The amount of effort by any one member of the team ebbs and flows during a case.  Circulators and anesthesia members who are not scrubbed in may fill the boredom with searching the internet, social media, etc… As a robotic surgeon, the more common phenomenon that I see is the resident or fellow on the computer or their phone when I am preparing to transition a portion of the surgery to them.  They often are doing other work (checking labs or directing patient care) but these distractions disrupt the flow and teaching in the OR.

I could go on with many other examples but I believe that I’ve captured the major causes of distraction in the OR.  Some of you who work in environments where a surgeon runs several rooms might think that this is just something a skilled surgeon must learn to balance to be successful but I can’t imagine that all these sensory and mental distractions don’t impact care especially in the setting of sicker patients or complex operative procedures.  I find that after a long day in the OR I am not as much physically tired as emotionally drained from having to manage these distraction for 10-12 hours.

The problem with distractions is far greater than infection control.  In fact, I am surprised at how few infections I do have given the churn of people coming in and out of the OR.  If you have read my other blogs, you might expect me to say that the bigger problem is efficiency.  While I believe that distractions create a great deal of inefficiency, I believe that it is an uphill battle to improve this.  Some of our inefficiency is baked into the academic model where teaching is a critical part of our mission- a mission that I strongly believe in.  Inefficiency also comes from the complexity of the patients.  However, efficiency could be improved with less distraction from the churn of people and decreasing sensory distractions that might add up to a 5-10% improvement each case.  It would be an interesting cost-effective analysis to perform and I would suspect that a health system that was willing to embrace this analysis could see large returns on investment.

The greatest problem with distractions is that it fundamentally dehumanizes the patient we are caring for and in the process, dehumanizes everyone involved in the operating room.  Like a three ring circus, the environment of distraction in the operating room creates multiple foci of attention of which the surgery and patient are only one of the centers of attraction.  In fact, the operative field becomes another sensory overload in the overall tapestry of the OR.  Everyone hopefully knows what we are technically there to do, but the distractions of smartphones, EHRs, instrument/sponge counts, time outs, hand offs become the immediate goals taking away from the meaningful work of caring for the patient who is someone’s neighbor, friend, parent, child, and/or family member.

Each one of us becomes dehumanized in the process because our attention is drawn to these small and sometimes unimportant tasks over understanding how our presence and action benefits the patient we are trying to heal.  This is accelerated by the constant churn in the room.  When we are treated like cogs in the machine where one person replaces another on what is supposed to be a team (think back to the surgical introduction at the time out), we begin to feel that our work is replaceable.  From personal experience and getting back to the issue of efficiency, that is not the case.  As I alluded to in my post on “Close to Perfect”, a good team makes for a great day not only because we get to take great care of patients but also because it acknowledges the importance and value of each member of the team.

What can we do about distractions and the dehumanizing effect it has on every person in the OR?  While I appreciated the reports from the American College of Surgeons, I believe it fails to acknowledge the realities of the day.  Our mobile devices have truly become life lines and silencing them or signing them out to the room would not prevent the other mechanisms (texts, emails, etc…) that people use to access us in the OR.  However, we should all make an effort to reduce the noise coming from our phones.  First, disable all the push notifications sent from some apps.  It seems like every app that is installed vies for our attention aside from pager or text function, nothing else truly needs to intrude in the OR.  In addition, a parking lot for our mobile devices should be created in the OR and rules should be set for what the circulator needs to respond to.  The circulator has a critical job to do in the OR and it is not to respond to text messages from a significant other asking about dinner plans.

Dealing with the churn of people in the OR is somewhat more difficult but it starts with acknowledging the problem.  Those in charge of patient flow need to understand the impact of the number and timing of breaks, of the number of learners that can be meaningfully served in any particular operating room, and not forget that we are here to care for patients.  I plan to try a couple of experiments in this scenario.  First, I will ensure that the patient is aware of every learner in the operating room.  As surgeons, we explain the presence of residents and fellows as part of the consent process.  Does the anesthesia team and circulating/scrub team make the patient aware of other learners in the OR?  While we need to promote the teaching mission of academic medicine, there should be a reasonable limit on the number of people in the operating room.  That number may vary but there is an upper limit.  Finally, and perhaps most important we need to restore both the patient’s and our humanity to the operation.  This starts with the surgical checklist.  Team introductions should mean something.  It should not mean that I am here for 15 minutes until my shift ends or that I can take a break during the critical portion of the surgery.  It means that we all take accountability for the patient and each other.  At one point, a colleague of mine suggested telling something meaningful about the patient during the surgical checklist.  This could be simple like Mr. X is a retired high school math teacher with three children and 5 grandchildren or more applicable to the case such as Mrs. Y was diagnosed with invasive bladder cancer, was able to get through but struggled with her chemotherapy and hopes to be able to get back to her volunteer work once she has recovered from surgery.

I’m not trying to preach but I would suspect that if we re-inserted the human element into the OR instead of treating it like Grand Central Station it would pay dividends for efficiency, health care costs, improved outcomes and most importantly the very meaning of why we are here- to alleviate suffering.  Thanks for reading and have a great week.

The Secret Life of Attendings

Having two teenage daughters and an 8 year old son, it can be difficult to get agreement on an activity during the rare moments when we have free time.  I’m fortunate that all my children enjoy going to see a movie in the theater as much as I do and, for the most part, they are able to agree on what to see.  Because of this, I have been able to see most of the recent animated movies without guilt or shame.  Without my kids, I would have had to order the movies “on demand” and watch them in the privacy without the scrutinizing eyes of others wondering what a middle-aged guy is doing at a “family oriented” movie alone.  I actually experienced this judgmental stare when I was on a long flight and watched The Secret Life of Pets.  The person next to me gave me that “look” which I repaid by being very slow to get up and move when they needed to go to the bathroom.  Judge not lest ye be judged.

Anyway, if you have not seen The Secret Life of Pets, it centers around the anthropomorphized experiences of house pets when their owners leave for the day.  The story centers around Max whose life is turned upside down when his owner adopts another dog (Duke).  On a walk, Duke and Max through unfortunate circumstances get sent to the pound only to be saved by a jaded bunny and their friends.

As an intern, I used to believe that when my attendings were not in the OR or clinic, that they were out enjoying free time or hours in their office writing, reading, or thinking great thoughts.  I felt that in many ways that their life of leisure was due to the blood, sweat, and tears of my fellow junior residents who managed all of the inpatient issues, took first call every night and weekend, saw and wrote up many of the clinic notes and consults, dictated the operative reports, made sure the x-rays were printed for the OR and that everything was just right so they could walk in and talk to the patient in clinic or perform the surgery without worrying about anything else.  While the attending physicians were off at some exciting national or international meeting, me and my fellow worker bees were left behind to do all the work.

My resentment extended to my more senior residents and fellows as well.  I always felt like the work (I’m using a nicer word here-  this is a family friendly blog) rolled downhill and while everyone was heading off to the OR to do exciting cases or learn about evaluating complex patients in clinic, I was left on the floor dealing with the “scut”.  I dreamed of the day when I would have more control of my time to do with it as I saw fit instead of countless people telling me what to do and when to do it.  I felt that my life would get better as I moved up the resident food chain because I would have more freedom and flexibility.

But with great power comes greater responsibility.   As I moved from junior resident to senior resident and chief, I realized that there was not less work, only different tasks and pressures.  Interestingly, the one sentiment that has continued to stick with me as I have progressed in my career is a strong distaste for shoving menial work to more junior members of the team.  I’m no saint, but I had such a bitter feeling about being asked to do work that could have often been done much more efficiently by the one scutting me out that I swore that I would avoid meaningless delegation if at all possible.  There is nothing more demoralizing to a team than when the leader is not willing to roll up their sleeves and share in the work.

However, my experience as a senior resident and the added responsibility of making clinical decisions about inpatients, supervising the more junior residents, doing research and writing papers, applying for fellowships, studying for in-service exams, and being prepared for surgical cases and clinic taught me that while I could do everything, I was never going to survive if I did not learn to delegate some responsibility.  However, I would never delegate something that I could do quicker or easier and would only delegate things that I could do better if I felt like it was a learning opportunity for the junior resident.  A perfect example of this is what we used to call FedEx.  Often the last cardiac case when I was an intern would end late in the day.  The cardiac fellow would typically call the intern to help close the chest.  Of course, in the beginning, I thought this was really cool.  The big needles, the bone goo, twisting the steel all made me feel like I was doing something.  But for the fellow this was their opportunity to leave the OR and let us transport the patient to the cardiac ICU which was typically a 30-40 minute ordeal.  By the time I was done FedExing the patient to the ICU, it was late and I still had to run the patient list with the fellow and update them.  Needless to say, I have avoided this scenario happening in my OR.

As a chief resident, while I was top of the food chain, I was also on call every other night for most of the year responding to calls from my interns and junior residents about issues on the floor or ER consults.  At that point, I dreamed of being a fellow where I would be seeing the patients and helping with the operations that I wanted in my future practice.  I would have time to do research and write papers.  I would have more time on the weekends to spend with my family and resume some hobbies that I let go during residency.  I might even be able to get errands done during the day.  Don’t get me wrong, I loved my fellowship.  My surgical skillset and confidence as a surgeon expanded rapidly and I was able to generate ideas, do research, and publish on subjects I found engaging.  But it also came with additional responsibilities that I had not experienced before.  I had my own patients in clinic and the OR that I was responsible for. My clinics were full of a variety of patients and looked nothing like the clinics I helped with during residency which had highly selected patients based on the surgeon’s expertise.  I would come in late at night or on the weekends to help manage complications and take people to the OR for emergencies.  I needed to ensure that my academic productivity was good so I could be competitive for a strong academic position.  I had the pressure of interviewing for jobs, negotiating with Departments and institutions and after long years of being underpaid and overworked, hoping to find a position similar to the one I felt my attendings during residency had- lots of interesting patients and surgeries, great staff and residents to support my clinical work, residents and fellows to mentor and collaborate on research, the opportunity for funding and leadership, time to spend with my family and pursuing outside interests- in essence a dream job that doesn’t exist.

Well, in many ways I have been fortunate.  I have continued to be able to progress on my career path.  I have awesome residents and co-faculty/partners that I work with.  I have a clinical practice centered around my areas of expertise.  I have been able to assume leadership roles and expand my skillset beyond clinical medicine.  But just like every step of the way I have described, this part of my career is not easier than the steps that came before.  While I have more control over my time, increasing clinical expectations and oversight by the Health System require that I account for all of my effort.  Much more of my time is spent doing office work than I would ever have dreamed of. There are also activities that attendings must do to continue to progress in their career that while enjoyable, add more complexity to life than a resident or fellow experiences.  These include a wide array of teaching responsibilities that you are constantly judged on by residents, medical students, and other learners.  There is also the growing desire to be able to get home and be there for your kids who are growing up so fast, who need your help with homework or simply to shuttle them to their next activity.  Finally, increasing expectations of local citizenship to the Health System or to various organizations add more responsibility and time that can fill every nook and cranny left over.

Then there are the changes that are brought on by the growth of an academic medical center.  I rarely work with the residents in clinic and see patients at several clinical sites.  In addition to the main hospital, I operate at a community hospital. While I get to work with advanced practice professionals, it is not exactly the same as working with residents (although I still get to see them in the main hospital OR).  Learning a different electronic medical record, different physicians to call, different culture all add additional stressors that I never experienced as a resident.

I am not complaining.  I am lucky and I know that.  My driving point is that our perceptions starting at the bottom is that the system is built like a pyramid scheme and you only have to persevere and make it to the top to enjoy the benefits.  But the life of an attending is not a secret life of excitement and adventure like some animated movie about animals.  My life is definitely better in many ways but it is no less stressful and I have more responsibility and accountability than I had at any other point.  So I would like to end this with a few brief points and lessons learned.  If you are a resident reading this and are cynical or bitter about the pyramid of organized medicine, I hope these words will give you some comfort.

First, remember, as cliché as this sounds, that life is a journey and not a marathon.  It does you no good to focus on some fantasy future and not appreciate the good things that you have in the present.  Sure life may be tough but you will miss so many good things if you are just trying to work your way up the next step in the food chain.  A lot of my angst and extra hours of work were related to positioning myself for a successful next step.  While I am happy where I am, I sometimes wonder what I missed getting here.  A corollary of this is that your career does not need to be a straight line to the top.  Circumstances change throughout a career either because we, as individuals, change or certain opportunities become blocked and other doors open.  If you constantly focus on “what next” thinking, you will miss the opportunities that come from taking the detours.

Second, remember that while career progression comes with benefits, it also comes with more responsibility and accountability.  No matter who you are, medicine is a life of service to others, most importantly patients but also to those above us and below us in the hierarchy.  To believe that getting to some predetermined destination will make you free and happy is truly magical thinking.  Rather, embrace that you chose a profession where your work benefits not only yourself but ultimately patients and the small frustrations become just that, small.

Finally, delegate appropriately and avoid buying into the pyramid scheme.  Hierarchies exist for a reason but they should not exist to serve the people at the top.  Rather, as I have learned, they should exist to appropriately align experience with responsibility and accountability.  The person at the top of the pyramid should have the most accountability and responsibility in service to everyone else.  But our pyramids need to be flatter and there needs to be greater overlap between different steps.  One way to do this is to avoid delegating everything downhill.  Sure, the people at the bottom are the least experienced and skilled but if you only give them the most menial and time consuming tasks to perform, then you should not be surprised to generate bitterness and perpetuate a culture where those who climb continue to push more work toward the bottom.  The daily grind must be broken up by opportunities for the most junior people to stretch themselves.  In addition, accomplishing tasks yourself flattens the pyramid by sharing burden, validating the importance of the work, and disrupting the hierarchy.  No one should be above what it takes to get things done for our patients in healthcare.

Thanks for reading this and please feel free to share any comments or thoughts with me.



Checks and Balances

It’s funny to recognize your own character traits in your children.  Is it because they reflect your own behavior or do they inherit these traits?  I lack the expertise to answer this but definitely see some of my character and behavior in all my children but especially my oldest daughter.  I have had to endure the same discussion at every parent-teacher conference since pre-school about how much they love my daughter’s enthusiasm but wish she would “shut up” ( my words, not theirs). She has a big personality which endears her to many but causes trouble with authority figures. I was editing her eighth grade graduation speech the other night and the recurring thread was about her as “the girl who talked too much”. At least she has insight.

I too, recall being sent to sit at the front of the class in elementary school for talking too much in class or seated at the “silent” table during lunch for speaking out of turn. It was hard for me not to ask a question that challenged the assumptions of what we were being taught. My most vivid memory of this was 9th grade English class where the unit subject was on the “hero” archetype. My teacher actually had us reading Joseph Campbell’s The Hero with a Thousand Faces and the idea that every story and movie that I loved could be boiled down to a relatively simple formula was so anathema to me.  I mean Star Wars had nothing to do with The Odyssey, right? This rankled me so much that I would think about new inventive counter arguments for each class to disprove the hypothesis. While my teacher was a patient individual, eventually she became frustrated and asked me to reserve my questions until the end of class so she could cover the subject matter.

That slowed me down but did not stop me. I seemed drawn to the opposing point of view dissatisfied with answers that felt like dogma or tradition. But over the years, I learned to temper my questions. I learned, like the gambler, when to “hold ’em”. At first it was subtle. I would wait until the end of a lecture or after a meeting to ask my probing question. Later, I chose to frame my questions as points of clarification to avoid conflict. I discovered especially in both the academic and administrative world that people tried to avoid conflict and viewed probing questions as a challenge rather than an opportunity to understand. More recently, I sometimes just hold my questions or comments knowing that it will not make a difference to leaders who have their mind made up already.

I can’t tell you when I assumed the same passive nature as I used to get frustrated by in others. It does make me sad because like my daughter, it’s contrary to my nature. And I believe that it aids and abets a growing culture especially in academic medical centers that discourages conflict.  But healthy conflict is critical to a successful culture.

Some of you may be stopping here thinking that my premise is preposterous. And if we were talking about the exchange of academic ideas I would say that you are correct. The academic mission is about innovation and fundamentally that requires questioning the status quo and subjecting new ideas, hypotheses, and research to scrutiny. Similarly, as educators, we encourage all our learners to ask tough questions rather than be passive recipients of knowledge.  We only need to go on Twitter to see the robust discussions that certain topics can generate.  But on the clinical side especially as it relates to clinical operations and administration, conflict is messy and can be viewed as a costly impediment to getting things done. Leadership wants buy-in (agreement) and quick implementation and questions and conflict serve to slow down the process.

Again, some reading this might believe that I have gotten this wrong. There is plenty of conflict and questions asked related to the clinical space and operations.  Again, I would disagree (I even disagree with myself). I find much of what passes as conflict and discussion as petty. It often seems more about politics than about issues that meaningfully impact the clinical care we deliver or the conditions in which we deliver that care. The bickering is more about who controls what, who gets to make the decisions, and who has ultimate authority rather than the what, why, and how that could drive positive changes to health care delivery.

The other counter argument to my claim is that many organizations have transitioned to physician and clinician lead organizations where our voices are part of the decision. The top leaders of many academic health systems are physicians, nurses, and others with prior clinical care experience. In addition, most important committees have doctors and nurses as decision-making members.  All of this is true but despite this, the voices and expertise of frontline clinicians are often not reflected in the decisions.

The first challenge with physician leadership is when does someone transition from being a clinician to being an administrative/operational leader.  In academics, we talk about the triple threat of the physician-scientist.  This is someone who excels in clinical care, education, and research.  We know that while these individuals exist, they are rare.  It is hard enough to excel in one space let alone two or three.  Similarly, while someone may have an MD, that does not mean they can be successful as a clinician and administrator-both require significant time and effort to be successful. As clinicians move further away from clinical care, they often make decisions in the same way that a non-medical administrative leader makes them. Often there is a heavy reliance on data and metrics because the clinical expertise has waned. Without the same degree of clinical “skin in the game” decisions get made from an organizational perspective without always contemplating the impact of those decisions on the local level.

Many organizations have tried to thread this needle of ensuring that physician leaders remain clinically active.  This typically translates into 1 day of clinical activity per week.  But one day per week does not translate into true clinical activity.  The work that physician leaders do is often compartmentalized to avoid spill-over into their administrative responsibilities.  While the intention is for these leaders to retain clinical legitimacy, these clinical practices do not reflect the daily clinical work of the people who are doing the bulk of the care.

A second challenge is that physicians are often engaged in committees and smaller leadership roles to serve as a “rubber stamp” to the decisions of senior leadership.  When a rank and file clinician comes to argue about how a new policy has negatively impacted their clinical practice, the accountable leader can point to their peers on the committee who were part of the decision providing the illusion of clinical input.  I say this because unless physicians on these committees are fully engaged and prepared to address the issues of the committee, they often can only absorb and make decisions based on what is presented to them rather than their own take of the source material.  Similarly, sometimes the most challenging physicians are offered leadership roles not to bring their diverse opinion into the process but rather to soften their impact and smooth the way for decisions that would otherwise meet resistance.

Finally, there is the fact that physician-leader roles are often “middle management”.  Take the example of a Clinical Department Chair.  As a surgeon who trained at Duke and went to medical school at Baylor in Houston, I was exposed to the idea of a Surgical Chair that seemed almost all-powerful.  Debakey and Sabiston seemed as if they were accountable to no one and had the ability to make almost dictatorial decisions.  I’m not saying that model is good.  I believe we can all agree that unchecked authority leads to abuse of power.  But I believe that we have drifted in the opposite direction.  The scope of the Clinical Department Chair has become limited to focus on research, education, faculty development, and philanthropy while the major driver of activity, clinical care and operations has been removed from their influence.  Most clinical operations sit under a faculty group practice which instead of flowing through Departmental authority rolls up to the Dean or executive leadership of an academic medical center.  Since most of the dollars reside in clinical activity, this places most Clinical Departments in a vulnerable position.  In order to obtain the funds to pay their faculty and support the other activities of the Department, the Chair must answer to the senior leadership.  Decisions of senior leadership are made in the interest of the organization and some Departments inherently win and lose.  However, the Department Chair in order to protect the interests of their faculty must serve as a conduit of these decisions to their faculty and staff.  Rather than being true advocates for their group, they become “middle managers” doing their best to comply with the decisions of higher leaders and protect their people.  This type of pressure can be difficult to handle and absent leverage, the Department Chair may be forced to acquiesce to decisions they might not agree with.

I know this sounds cynical.  It also sounds relatively cliché since many complex organizations have these struggles.  It is true that all politics are local.  The difference for academic medical centers is that fundamentally the work we do is by the hands of people for people.  That makes the issue of who is engaged in meaningful decisions different because failure to make decisions with a clinical orientation can have a negative impact on both clinicians and patients.

There is no easy answer here.  When I was the medical director of our Cancer Center, I saw the other side of this argument.  Sometimes decisions have to be made that are not going to be popular with others.  It is painful and frustrating to have to obtain buy-in for every decision that could impact the way work is done but, having tried to implement change without this process, I can tell you it is doomed to failure.  Big changes require real engagement and the willingness to adjust the plan based on input from the people who actually get stuff done.  So I have some suggestions for clinicians about how to meaningfully engage to help their organization and provide oversight of their leadership.

First, there is an obligation to be present when asked to serve on a committee or assume a leadership role.  Ninety percent of leadership is showing up.  This is because your absence creates a vacuum that allows others to fill in the gaps in your absence but use the fact that you are a member of the committee to add legitimacy to the decisions.

Second, clinicians should not assume leadership roles or committee memberships that they cannot fulfill.  It might be nice to be seen as a leader but if meetings are scheduled in the middle of clinical activity or the committee, leadership role is under-resourced to accomplish the charge, it fundamentally becomes more about the rubber stamp and less about the work.  Being a party to that only lends the sham process credence.

The third is really the next step of the first.  It is critical for clinician leaders to be prepared when participating in committees.  Don’t settle for the executive summary when discussing important issues.  Ask for material well in advance of a meeting so you can review it and ask meaningful questions.  Ask for additional data or discussion when something is not clear.  Take your role as a clinician leader seriously.  To avoid being a rubber stamp, clinicians must ask the tough questions that represent the interests of clinicians and patients in their organization.  The line is drawn where questions serve others and not the individual.  Questions that are self-serving that turn things into a political process are why leaders think clinician engagement so challenging.  However, if clinicians approach the process to improve the outcome for all instead of trying to tear it down, then our voices are value added.

The final comment encompasses a few points.  Many organizations are embracing the concepts of diversity, equity, and inclusion and I believe strongly that bringing this diversity to the process of decision making is critical.  But simply having diversity at the table does not mean that a diversity of opinion exists when leadership is looking for a rubber stamp.  In addition, people assume that a single diverse person represents the opinions and ideas of the group they may appear to represent when that might not be the circumstance.  We must recognize this bias and value not only the diversity of gender, ethnicity, identity, religion, etc… but also the diversity of opinion and ideas that exist within every group.  Failing to do so risks stereotyping which serves no one’s interest.

And while my suggestions above represent ways in which we can engage respectfully in the process, ultimately, having clinicians in the organization at the table requires us to serve as a check and balance to runaway consolidation of authority that can threaten the core health of an organization.  Academic Medical Centers are not democracies but they are, like the Universities they are connected with founded in an environment where faculty self governance is engrained in tradition.  That self-governance is designed to protect faculty and staff against the whims of leadership or political pressure that may ethically challenge what we do.  While civil discourse serves as the best mechanism to address conflict and disagreement, I have always struggled with who defines civility.  I was in a meeting recently where I openly disagreed with a leader and she as forcefully disagreed with me.  At the end of the meeting, a third leader pulled me aside and felt that I was overly aggressive with my questions and comments.  There was no yelling or personal comments- only disagreement on the topic at hand.  When the person who I disagreed with came up to me and our third colleague, she felt that the discussion had been civil and productive.  Civility is not about repressing disagreement and healthy conversation.  Civility draws the line when disagreement becomes about individual attacks as opposed to topic of discussion.

While I am not the same contrarian as I was during my school years, I also realize that not asking questions and seeking to understand is contrary to my nature.  Our value as clinicians in being part of the process comes from being willing to ask the tough questions to serve those who we care for and represent.  It can be messy, slow, and inefficient but it creates a culture that values the voices and opinions of everyone.  That’s real diversity as the value of an individual is judged not by who they are but what they think and how they contribute.  While I may have come home from parent-teacher conferences and provided my daughter the feedback of her teachers, I have never discouraged her from asking the tough questions and being an active participant in her class.  As doctors, nurses, and other clinicians and staff, we need to remember that lesson for ourselves and teach those around us and provide the appropriate check and balance to leadership who will benefit more from our presence than our rubber stamp.