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.

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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.

 

 

Life is Iterative or Why Hope Springs Eternal

I’ve always liked the word “iterative”. Perhaps it is because it captures the essence of what daily life is all about for me.  Its not a word I grew up hearing and I probably had to look up its meaning in the dictionary the first time I heard it as an adult.  In digging around looking for definitions more recently, I found that iterative comes from Latin and is the active verb of the noun iteration. To summarize, iterative means repeating a process to achieve a desired goal using prior information to improve the process. While often applied in scientific or mathematical processes, it is very applicable to almost any process in our lives.

The essence of this word that I believe captures human experience is two-fold. First is the idea of repetition and that much of what we do everyday lacks variation or change. The second is the idea that there is always a chance to do something better or improve. Let’s break these down.

If you think about a typical week, most of our existence is fairly repetitive. We wake up around the same time every morning, eat the same breakfast, get to work the same way, probably have a consistent work schedule week over week, go home the same way, etc… You get the point. Viewed in this way, our lives are dull. What we do, how we do it, when and where we do it, and the expected outcomes are consistent.

As a surgeon, I would argue that my life is more varied but I would be wrong. Pull the time scale back to the months or years range and the pattern becomes consistent. Sure there are blips that alter the pattern. Various life events such as births, special occasions, travel, natural (or unnatural) disaster, or illness disrupt the repetition but viewed through a broader time scale, they are small deviations in an overall stable pattern.

This on the surface seems like a depressing view of existence but there is value to the repetition. It provides all of us stability and for many processes, this stability creates consistent results. Think about the amount of energy you would need to expend if you had to figure out a new way to get to work every day or had to perform your typical work different each time. While some of us enjoy the chaos of constant change, this translates into a great deal of energy with unpredictable outcomes.  It would be exhausting if every action we performed had to be reinvented each time.  As a surgeon, I value consistency. If I had to come to the OR and use different types of instruments than I was used to each time to do the same surgery, it would be a struggle and would not be beneficial for patients.

This repetition also creates reliability. My kids need to be picked up from school at a certain time, taken to their activities and lessons after, and have time for homework, dinner and get to bed at a certain time. If chaos reined over repetition, this would create stress and anxiety for all involved.  As creatures of habit, the reliability of repetition buffers us from the whims of change.

But life is not all about repetition without change and this is why I believe the word iterative captures life so well. If instead of zooming out on our time scale to see the stable pattern, we zoomed in to the seconds, minutes, and hours of our daily lives, we could then see the rich variation that allows us to to improve upon the repetition. This is at the heart of what makes life interesting- the almost countless unconscious and conscious decisions we make every day that slightly change the trajectory of our lives.

I’ll give you an example. When we moved to Ann Arbor, we enrolled the kids in “Learn to Skate” when they were old enough. It seemed like the thing to do. It’s too cold to do anything outside for months on end but we needed some type of winter sport for them to burn their almost inexhaustible energy. All three of my kids now figure skate and about 6 years ago, my wife joined them on the ice and has been progressing in skill through the adult programs and competitions. A little over a year ago, my family asked me to be in the Holiday Show with them at the rink. I never really skated before and did it mainly to be a good sport.  I like performing and I thought it would be fun to do something with the entire family.

This required me to buy some skates and take a few lessons with their coach. Most people look at figure skating like dancing- pretty people in costumes gliding across the ice. After my first lesson, I learned that the physical requirements were high- strength, balance, and attention to detail distinguished the people who looked like they were exerting almost no effort on the ice from those who were not as good.

Despite my initial reservations, I have continued to skate.  I spend enough time at the ice rink picking up and dropping kids off that it made sense to do something productive while I was there.   I do a weekly learn to skate class, take a half hour lesson, and practice on my own. While there is a great deal of repetition, what I find fulfilling about learning to figure skate is that just because you are capable of performing a certain move, there are always small adjustments in posture, blade position, balance, etc… that you can make to be better. In fact, the process of learning to skate is iterative to an extreme because as you progress, it uncovers weaknesses in the more fundamental skills that you have to go back and improve.

Of course, this is true of most sports or technical activities. As a surgeon, while I may perform the same 8-10 operations on a regular basis, I am constantly trying to be better and to help those I work with and train be better. This comes from iteration in the small details. I once worked with a surgeon in my training who seemed to re-invent each surgery every time. It would drive me crazy because there was no repetition to create the stability and consistent outcomes that surgeons and patients expect. To me, improvement in a iterative life means paying attention to the small details and learning what does and does not work from previous effort. While major changes are sometimes required in surgery as new technology or techniques allow us to make quantum leaps forward, it is the learning and attention paid to the small details that cumulatively add up to improvement most of the time. This is true for a surgeon as much as it is for a lawyer, electrician, or manager. Our lives may have a certain repetition when viewed on a broad scale but the richness of our existence comes from the small decisions and changes we make every day to try and be a little better at what we do or to be a better person.

Sometimes our decisions do lead us down the wrong path. We all make bad decisions, big and small. When we recognize them, it is sometimes possible to correct course. Some of us fail to recognize that our small choices lead us to bad places or negative outcomes. Even worse is when we fail to recognize the negative consequences of bigger decisions. Ultimately, our decisions catch up with us and the normal human response is regret. It may seem like there is no way back from the dark place we have lead ourself to.

But if we accept that life is iterative, we can all learn from bad decisions and outcomes and make conscious decisions to change. Like most of us, I have experienced regret in my life. As a doctor, we all experience bad outcomes. The advice from more experienced surgeons is to learn and be better for our next patient. But this does not take away the pain and suffering that our decisions may have caused. To me what has helped when my patients have experienced less than ideal outcomes is to make the choice to remain present, to engage. Sometimes there are no actions that can reverse what has happened but just being there to listen, to bring in others who can help, and share the burden with the patient and family provide a path forward instead of merely filing the lesson learned and moving on. I’m not advocating to be weighed down and dwell on every bad decision or outcome, but only looking forward prevents me and the other people involved from truly learning and healing.

In my personal life, I also live with regret- things I should have said or done or failures to deliver on things I promised. These are painful and I carry around many of these failures as a constant reminder of where I have not been the person I wanted to be. I know it sounds cliche, but there is almost always the opportunity to change, to do or be better. This does not come from grand gestures but the small actions and decisions that are part of an iterative life. It may come from simply apologizing to the person we let down or making a conscious decision to change the way we behave. But it also comes from being willing to forgive ourselves. Moving on may allow us to bury our mistakes but it doesn’t allow us to heal. Making the effort to make amends when we can and to forgive ourselves for these mistakes allows us to both incorporate the lessons learned into future actions and move forward.

I subtitled this Post as “Hope Springs Eternal”. No one else I know uses this expression so I have no idea where I picked it up from. It comes originally from Alexander Pope’s 1734 “Essay on Man”. To, me this phrase captures the driving point of this post. In our daily lives, I believe we have free will and the ability to make choices and decisions that impact our trajectory. I know circumstances are stacked against many people in this world but we do have the ability to choose how we behave or act in the moment. Most of these choices amount to nothing but some have an impact on us and those around us. These outcomes may be good or bad but we have the ability to learn from them and try to be better the next day or time. Nothing should be so hopeless that we can’t make a choice to try and turn things around. While much of our existence may seem repetitive, hope does spring eternal in the small choices and decisions we constantly make. It is by these small actions that we can make our own lives and those around us just a little bit better.

The Thrill of Victory and the Agony of Defeat…

Like much of America, I have been spending my leisure time watching “March Madness”.  I have a vested interest.  I learned to love college basketball as an undergraduate at Duke University from 1991-95 which only continued to grow when I returned as a urology resident from 1999 to 2005.  I’m not here to offer analysis as there are far more expert people than me if that is your interest.  However, the unpredictability of the outcome has stirred some connections in my mind that I would like to share.

Caring for patients has several parallels with sports.  I agree with many people that the use of “war” or “battle” analogies when describing patients’ treatment for cancer is seriously flawed.  I would like to consider this metaphor from a different angle which revolves more around the patient-physician relationship than the patients’ relationship to their disease.  What I believe makes college basketball exciting and different from professional sports and even other college sports is that success is heavily dependent on how the team functions together, the extent to which they communicate during the game, and the culture the coach sets for the team.  Sure, a team might have success during the regular season with a superstar player surrounded by average talent but can be outmaneuvered during the tournament by a well coached team that works well together.  For example, Duke has managed to pull off close wins in the last two rounds against excellent teams not because Zion Williamson dominated the game but because the team worked well together and benefitted from Coach K’s expertise. Unfortunately those tight games fell in the opposite direction (Michigan State) in the Elite 8.

Many view this as a tired analogy.  We have heard it over and over again- medicine is a team sport.  Often people are referring to the group of clinicians that must come together to help manage often complex medical issues.  That team is critical and its importance is growing as medical care becomes more complex, our patients’ medical issues are more challenging, and our degree of specialization narrows our focus requiring us to engage others to help.  The core team, however, is the patient and the physician (or provider) and I have had several experiences over the last few weeks that have reminded me of how important this relationship is.  These patients have reminded me, as Jim McKay used to say on “ABCs Wide World of Sports” of the “Thrill of Victory and the Agony of Defeat.”

A few weeks ago, I had one of those rare conversations that remind you of the impact that a physician can make on a patient’s life.  It is easy to get tunnel vision and focus on the problem, the treatment options, the mitigating factors that influence treatment and forget the physical and emotional burden that disease places on the person.  About 5 years ago, I was referred a very active woman with a complex surgical history with chronic kidney disease and a 4 cm renal mass.  Her local physician said because of her prior surgeries that surgical intervention was high risk and he would recommend surveillance.  While she was in her late 60s, she had no other significant medical issues and was the primary caregiver for her grandchild.  At the original visit, we established that she needed to recover quickly and did not want to be on dialysis.  Removing her entire kidney through a flank approach as her local physician suggested as an alternative to surveillance was not an option for her.  She was prepared, educated and asked great questions.  Not to delve into details, I offered her an approach that met her needs and she left the office to discuss this with her family.  Ultimately, we pursued surgery and she did well.

Last week, when she returned for her last surveillance visit with me, she brought her grandchild’s high school graduation pictures from the prior summer to share with me.  She has remained cancer free and her renal function remains stable and because of this, she has been able to continue to nurture and support her family.  She attributes this to the shared decision we made together.

Of course, not every surgery is a complete victory.  Walking out of my clinic, I bumped into one of my patients who I operated on over 10 years ago for bladder cancer and several years after that for a recurrence in the upper urinary tract.  He originally presented to me after being treated for over a year by another urologist.  He came armed with questions and concerns about losing his bladder and quality of life.  We reviewed options together and initially, he was frustrated by my recommendation to remove the bladder.  However after several conversations and a second opinion, we ultimately did pursue a cystectomy and continent diversion.  While he has done great from a functional standpoint and has been able to travel and spend time with his family, he did develop metastatic disease and has had several standard of care and trial treatments that have kept his cancer in check.  He attributes his overall good quality of life to the decisions we made over 10 years ago and while I see him infrequently in clinic, I have had the great fortune to get to know him and his family and my life has been made richer because of this relationship.

And then, there is the agony of defeat.  Defeat can occur in several way in the patient-physician relationship.  Sometimes, like any relationship, the connection is never formed.  Other times, the relationship is soured by poor communication or irreconcilable differences.  Sometimes, the problem is not solvable (or could be better managed by someone else).  Finally, despite everyone’s best effort, sometimes there are bad outcomes.  We all experience our share of victories and good outcomes.  Similarly, the defeat informs us and makes us better doctors and human beings for our future patients.  Recently, I had a very elderly gentleman with locally advanced bladder cancer.  While his intellect was sharp, he had significant cardiac disease and physical limitations that precluded major surgery.  His family has been very involved and we discussed the spectrum of care options from routine endoscopic resection to chemo-radiation to palliative care.  I engaged colleagues in urology, medical oncology, and radiation oncology in the discussion and ultimately we elected chemo-radiation after maximal endoscopic resection.  Unfortunately, treatment has left him with residual disease and a poorly functioning bladder that has led to several hospital admissions for acute kidney injury.  We tried to teach intermittent catheterization but this caused bleeding.  He kept pulling out the catheter we left in place and medications seemed to worsen his cognitive function.  While there is no easy solution, what has made this manageable for all involved is a willingness for me, his family, and him to communicate.  We discuss what is possible and what is not.  I acknowledge where I don’t know the answer and approach his care with humility to ask for advice from colleagues to see if there are other options.  On the other side of the relationship, the family has been engaged and go the extra mile to be proactive about their father’s care.  Ultimately, we have spoken honestly and everyone is realistic about likely outcomes.

There are of course the patient’s where you really neither win nor lose.  A few weeks ago, I saw an elderly but healthy patient for a minor problem.  All the lab tests and images were stable and under normal circumstances, this would have been a quick visit.  In examining the review of systems before walking into the exam room, I noticed that depression and anxiety were checked off on the list.  I have seen this patient for a number of years and they approach life with optimism and a smile.  When I entered the room, I performed an exam and reviewed the results giving them a clean bill of health.  But then I asked about the items she reported on the review of systems.  She explained to me the multiple life stressors that had come at once into her life.  She had no one she could really talk to and very little social support.  I am a urologist and surgeon but I realized what she needed more than anything else, was someone who could listen.  She was not looking for someone to solve her problems or share her burden but only to sit quietly and be there.

As I write this, I realize the common denominator to providing good care whether the outcome is a success or not or somewhere in between is communication and being willing to listen.  I have had the fortune to uncover significant medical problems over the years not because I am the most skilled at physical examination or because I run extra tests but because, like the last patient I described, I am willing to commit the time to listen.  In her case, she was appreciative of just having someone to share with and I was able to connect her with our social worker to provide additional support.  Other times, listening to patients symptoms has allowed me to diagnose diabetes or arrhythmia that have a greater chance of impacting the patient’s life than what they were sent to me for.

The “win” in medical care is often not the outcome.  It is the connection that is made between patient and physician that acknowledges our shared humanity.  Over the past several years, there has been an increased interest to link patient satisfaction to compensation.  Patient satisfaction treats the patient as nothing more than a consumer/customer and physician and health care systems as nothing more than companies delivering a service or product.  As such, patient satisfaction often casts a wide net that can include questions on quality of the food in the hospital, cleanliness of the hospital or clinic, and other items that are not directly related to quality or outcomes.  In fact, there are enough studies out there that show there is a poor correlation between satisfaction and quality of care.

This is because sometimes physicians must make recommendations that patients don’t want to hear or point out problems that are uncomfortable for patients.  Sometimes we have to let patients know that the choices that they have made have resulted in disease and that they must make hard choices to correct course.  Sometimes, I have to say no to requests for medications or treatments that I know will not work or let patients know that the data does not support the choices they are making to treat their disease.  What has helped me bridge the gap between customer and patient is treating everyone like a person and allowing patients to see me as a human being and not just a doctor.

In many ways, I believe this push towards patient satisfaction as a metric may have the same negative impact as the use of “pain” as the “additional vital sign”.  Just like the latter contributed to the use of narcotics to the point of our current crisis, the use of patient satisfaction will drive the investment of resources to improve scores but not necessarily care.  Better food, nicer hospital or exam rooms, and seeing patients within 15 minutes of their appointment may help scores but they do not reflect the true value that a patient may or may not get from an encounter with their healthcare provider.  Of course, CMS argues that they are focusing on how patients EXPERIENCE their care and not satisfaction.  While this sounds nice, I believe the subtlety is lost on stakeholders.  However, questions related to communication and information do get close to what needs to be answered to understand whether patients are actually deriving value from their experience but I believe it is hard to capture the real experience with a survey instrument.  I am honestly worried that the emphasis on the metric will actually detract from a truly meaningful relationship between physician and patient.  While we don’t win “March Madness” with everyone of our patients, working together, communicating and listening, and acknowledging the shared humanity of patient and physician (or provider) allow us to make it further into the bracket than working separately.  I believe that when we emphasize that partnership, we all have a chance to win.

It’s The Most Wonderful Time of the Year

While you might believe that my title is an ode to Christmas, you would be wrong.  In addition, you would be mistaken if you thought I was about to write about the coming of Spring following a cold and miserable Winter in Michigan.  As an academic surgeon who trains residents and fellows, this is the best time of the year because we get to see the fruits of our labor.

Being a faculty member in an academic residency training program is a little like the movie “Groundhog Day” except on a lengthier time frame.  Each year, we welcome new residents into our training program.  They come armed with four years of medical school that has exposed them to the foundations of basic sciences as well as robust clinical exposure across the spectrum of medical care.  In many ways, the medical school curriculum has advanced to include concepts of professionalism, system and practice-based learning, and a better understanding of the broader concepts of health care delivery.  But all this education prepares people variably for the essential transaction that occurs between patient and doctor.  That first day of internship for many young doctors is “shock and awe”.  Translating didactic and practical learning into actual patient decision making can seem overwhelming.  Sure, an intern has their senior resident and attending to guide them but fundamental to any training program is paving the trainees path to independence so that they are prepared to care for their patients.

Each step of the progression for a resident begins the process anew building upon their previous experience.  For example, a surgical intern learns how to care for patients recovering from surgery, readmitted to the hospital, or those with conditions best managed by surgeons.  They also learn who to work with and how to progress care in the complex ecosystem of the hospital and health system.  While they may have had experience with this during medical school, every health system has its unique culture and workflow that an intern needs to grapple with.  The following years are filled with exposure to progressively more complex surgical training, learning how to exercise clinical judgement to help their patients make good decisions, and acquiring additional skills that will help them achieve success in their future careers.

And that is why this is “the most wonderful time of the year” for both faculty, residents, and fellows in a surgical training program.  Much of the hard work of acquiring the skills needed to be competent at a particular level of training have been achieved at this point of the year.  The massive ship of a clinical service runs smoothly with only minor adjustments required.  The rest of the year can be devoted to refining these skills and preparing the resident or fellow for their next step in the process.  Because of my clinical practice, I am exposed to residents mainly at two points during their surgical training.  The first is early on as residents work with me in the OR learning endoscopic/laparoscopic skills.  The second time is during their more senior years where they work with me caring for patients with urologic cancer and learning robotic surgical skills.  Along the way, I have the fortune of working with residents in the hospital caring for inpatients and in my clinic where we focus on evaluation and shared decision-making with patients around the treatment of their condition.  By the last 1/2 to 1/3 of the year, most of our trainees have the fundamentals mastered and we get to transition from “good to great”.

I obviously don’t work in isolation.  Both my faculty colleagues and senior residents have imparted their expertise to residents along the way.  As a teacher, I have come to appreciate that we all have our strengths and weaknesses and I am fortunate that I am faculty in a training program that has skilled educators which complement each other’s strengths.  As such I get to focus on what I am good at which I like to refer to as finishing school.  I expect those who are working with me to be able to cut, tie, and sew.  I also expect that our trainees know about the patient and the steps of the surgical procedure before they participate in a case.  Once I am confident in their abilities, my focus is really helping my residents accomplish three goals.

The first goal is efficiency, not speed.  Every surgery is composed of different steps with different levels of complexity that are connected and feed into the next step.  The goal of a surgeon is not to be fast.  It is to move efficiently through steps of the procedure where immediate risk is low and there is minimal impact to functional or oncological outcomes.  However, a resident or fellow must also recognize when to slow down and take their time when their technique does influence outcomes because of the nature of the tissue or the reason for the step of the procedure.  Overall efficiency comes from knowing when to move with purpose and when to slow down.  It also comes from constantly analyzing the steps of the procedure and understanding what movements and steps don’t add to the progression or outcomes of the case and eliminating them.  Another key component is thinking like a chess player and communicating the next several moves and what is needed to the entire surgical team.  We can’t always guarantee we are working with our usual crew and engaging the entire surgical team by clearly outlining next steps and needs helps everyone to work together efficiently.

The second part is exposure.  Surgical training has changed a great deal over the last 20 years.  Gone are the days where an attending left the room and came in only to perform or assist with the “critical portions of the procedure”.  Our patients expect their surgeon to perform the surgery and I deliver on that promise.  However, we as teaching faculty have an obligation to prepare our residents to go out in the world as safe, compassionate, and skilled surgeons who can make good decisions about whom to operate on (and who to not to) with reproducible outcomes.  This can still be accomplished in our “hands on” training environment and I believe a key component is to have the residents learn to use their retraction and assistants to optimize their surgical view.  For robotic surgeries, the way I have seen many surgeons teach is to hand off particular steps of the surgery under close observation.  Many times, they have already set up the retraction and instructed the bedside assistant so that the resident only has to do the dissection in an already optimized field.  This is not what a resident needs to learn at this time of the year- they already know how to do that.  What they need is to first emulate good exposure and second, be expected to set up their exposure when progressing the case forward.  Learning how to optimize exposure is the fundamental base for safe and efficient surgery that many people do not figure out until several years into practice.

A third component is staying out of trouble.  Of course good exposure keeps you out of trouble to some extent.  But more important is having a strong understanding of the anatomy related to the surgery that is being performed.  If a resident knows the anatomy then they can anticipate where problems may occur and avoid them.  Similarly, knowing the anatomy informs how a surgeon exposes to visualize all the critical elements in a field.  At this time of the year, I expect a resident to articulate how these elements of anatomy are informing their surgical decision making.

My greatest satisfaction is to help my residents/fellows achieve these finishing touches that will allow them to safely and effectively care for their patients as they take their first job or enter fellowship.  But it is not all fun and games because there is one final piece that I try to teach that is somewhat in direct contradiction to how we think of surgical training in this day and age.

The current dogma is that people learn best by reducing the tension in the environment.  I don’t disagree.  It is hard to process information when you are constantly being scolded or yelled at.  But it is hard to argue that surgery is not a high stakes environment and we need to prepare people to perform under pressure.  Our Department was recently given a presentation by the head of security for the health system and his words summarized the critical nature of being able to respond during a crisis.  He of course was talking about a security threat but these words ring true in the operating room as well.  “We don’t rise to the level of our expectations, we fall to the level of our training.” (Archilochus, a Greek lyrical poet)  If we never test how someone performs under pressure, then they will not be prepared when the time arises.  At this time of the year, I try to shift my expectations from teaching skills to teaching performance.  Reading through my previous resident evaluations, I feel that some of my former trainees appreciated this.  I also have received feedback that former trainees have heard my voice in their head that has helped them deal with challenging circumstances.  While I am not a sadist, I take great pleasure is seeing trainees rise to expectations because I know their patients will be well cared for and they will have the confidence to be successful.

This experience is not unique to medicine.  Other professions have the great privilege of seeing their student, apprentice, or trainee transform over the course of their education.  The rest of the year is not so bad but being able to transmit hard earned lessons from my experience to a resident who can now understand is a true joy.  It means they will be better equipped than I was to tackle that next step.  I continue to work hard and learn every day but my hope is that I will help those around me be better.  It truly is the “most wonderful time of the year”.

 

The Populism of “Medicare for All”

I’m just going to come out and say it.  I believe that the concept of “Medicare for All” is populist rhetoric aimed at engaging the very progressive and left leaning base.  In the next several paragraphs I will try to explain (my opinion) why this type of populism takes us further from securing the health and wellbeing of America.    

Populism is a political movement that claims to represent the “will of the people”.  Populism is on the rise globally and it is not isolated to either end of the political spectrum but lives on both extremes speaking for those who feel disenfranchised from the mainstream.  The United States has a long history of populism.  One interesting example of populism that is applicable to our current discussion is the rise of the “Tea Party” movement.  The Tea Party rose up following the election of Barack Obama around 2009 at least in part as a reaction to the Affordable Care Act.  Although there is not a unified political platform, politicians who arose out of the Tea Party movement in general opposed universal healthcare, supported lower taxes, smaller government, and increased fiscal responsibility.  The success of this movement came from grassroots support at the local level with an underlying distrust of the Obama Administration. 

The support for “Medicare for All” has a similar feel to the Tea Party movement albeit on the other side of the political spectrum.  It seems like a reaction to the current administration’s efforts to undermine the Affordable Care Act.  Just like the Tea Party shifted the Republican Party more to the right, the progressive movement advocating for environmental and economic justice is shifting the Democratic Party further to the left. Like the populism of our history, there are good elements to the arguments.  Prior populist movements responded to inequity and unfair advantage held by certain groups over others (such as supporting anti-trust movements or women’s right to vote) and our current circumstances reflect an even greater inequality in this country that translates into decreased opportunity for many based on socioeconomic status.  The progressive element of the Democratic party and the wave of newly elected officials to Congress, State, and local government are unmasking the illusion of meritocracy in this country that we need to grapple with if we want all Americans to have an opportunity to succeed and contribute in our nation. 

But also like the other populist movements, there is a negative aspect to the rhetoric.  The current discussion of “Medicare for All”  is less about race or national identity and more about an economic divide that casts those who are financially successful as morally inferior.  There seems little distinction between those who obtained their wealth by inheritance and those who are achieving success through hard work and innovation.  As a doctor, this concerns me.  First, I was not born to wealthy people and while I was lucky that my family emphasized education, I obtained loans for college and medical school which I continue to pay many years after completing my education.  While I am well off and can provide for my family, I do this through working long hours having sacrificed at least a decade of my life as a low paid resident and fellow working even longer hours than I do now.  Like many of my friends, I have pursued academic medicine which has allowed me to care for complex patients best served by the resources and skill of my institution, educate our future doctors who will care for people in the community, and contribute to the advancement of medical science through innovation.  While I make less than my colleagues who chose non-academic careers, my life is rich and each of my days brings me new challenges.  Progressives will argue that I have benefited from the labor of others that have contributed to my success and I won’t argue that.  But does my hard work and success make me the bad person? 

This is the fundamental problem with a policy like “Medicare for All”.  It is not really being put out there as a reasonable solution but as a tool to divide and polarize people politically.  I don’t think anyone would argue that people are entitled to health and wellbeing as a right.  But I disagree that healthcare as we currently define the services provided under Medicare is a universal right.  In my experience, medical issues tend to break down into two categories.  The first are medical issues that occur for the most part out of no fault of our own.  We can quibble on the details but many childhood illnesses fit this bill as well as diseases in any age group that have no apparent etiology or caused by infection.  Similarly, people injured by crime, accidents, or other circumstances in general did not bring medical misfortune upon themselves.  The other large category is disease that we bring on ourselves.  This occurs by choices we make in diet, exercise, drug/tobacco/alcohol consumption that lead to changes in our body systems and organs that result in disease.  If we provide universal healthcare coverage to everyone, we are saying that people are not accountable for the choices that they make that affect their health and wellbeing.  This means that a person who does make good choices in terms of diet, exercise, sleep, alcohol consumption, tobacco or other drug use bears the same cost as someone who chose not to care for themselves. 

Defining how an individual should behave and how that influences their medical coverage is not a government decision.  We as individuals in a free society should have the ability to make choices that may not be in the interest of our health and wellbeing.  However, we as taxpayers should not necessarily have to bear the cost of others’ bad decisions.  That being said, even when we think people are making individual choices, there are outside influences that impact their health and wellbeing.  Issues of clean water, access to healthy/fresh food, clean air, safe housing and neighborhoods, parks and public spaces to recreate in, and availability of preventative services (vaccines, screening) have a much greater impact on the health and wellbeing of a population than any doctor or “Medicare for All”.  It is hard for anyone to argue that we, the people, do not have a right to these basic resources and it seems like these issues are within the purview of local, state, and national government to secure these through allocation of our taxes, zoning, and other policy. 

But let’s play devil’s advocate for a moment.  Let’s say that we could somehow get our politically divided nation to agree to universal healthcare and a single payer system such as “Medicare for All”.  Let’s assume that everyone would agree to raising enough taxes to fund the enormous cost of providing universal healthcare.  Do we really believe that a single centralized payer is the best way to allocate resources?  Are we confident that resources will be distributed equitably and efficiently and that will translate into improved health and wellbeing of all Americans?  Supporters of universal coverage point to most other developed nations as the rationale for this policy.  But the truth is that very few countries actually have a centralized single payer.  I’m no expert on this but in my brief review, the solutions for universal coverage range from a single payer to employer mandated coverage (Switzerland) to local collection and allocation of taxes to support healthcare (Denmark).  While Medicare is a single payer for our population over 65 years old ( and other select populations), it is accompanied by multiple third parties that provide supplemental insurance, prior authorization, review of reimbursement for hospitals and physicians, compliance oversight, funding for graduate medical education, and a myriad of other factors that make this a bureaucratic monolith.  Adding everyone on to this program is not a simple matter of expanding the existing infrastructure but would exponentially increase the complexity of an already complicated and inefficient structure. 

The last argument I want to make relates to my role as a doctor.  We as doctors have benefited from Medicare and support of medical science by the federal government.  Despite the fears of the Affordable Care Act, we as doctors and other healthcare providers have had the ability to care for patients that previously would not have had access to care either through the insurance exchanges or expansion of Medicaid at the individual state level.  Of course, this has not been a free lunch for physicians or Health Systems as I discussed in my last blog.  It has been accompanied by a tremendous increase in regulatory and clinical oversight, barriers to delivering care through prior authorization, narrow networks, and payment structures based on hitting metrics or adhering to guidelines.  This is a messy time to be in healthcare delivery but the one upside is that it has got everyone thinking about how our fragmented system can best deliver value-based care.  The efforts of all stakeholders as they attempt to grapple with the new world order are actually real time experiments that we can study to understand what is and is not working well in health care delivery. 

I am concerned that if we moved to a single payer model, that we would lose this innovation in two ways.  First, there is no impetus for a single payer to run any experiment.  They can set the reimbursement for a service that encourages certain services being provided and discourages others.  As such, the incentive for those who deliver healthcare to innovate goes away.  Sure, there will be an effort at reducing costs for health systems to maintain their margin but this is only one aspect of innovation in healthcare delivery and ignores the advancement in medical science that takes place at a rapid pace.  Medicare does have the CMMI, ACO, and other programs but I would argue that they do this because of their role in helping direct care for other payers or cost reduction and in the absence of other players in the market, that role would go away. 

Second, a system that is designed to deliver health care services to all will naturally need to constrain choice, choose what to cover, and ultimately ration healthcare to contain costs (especially when we do not address the root cause of our health problems).  Naturally, with less financial and innovative opportunity, talented people will choose to invest their efforts elsewhere.  People who would have pursued a career as a doctor, physician assistant, nurse practitioner, nurse, pharmacist, or other healthcare professional might choose to invest their efforts elsewhere.  We already have a shortage of clinicians in our country especially in rural areas and this could exacerbate this crisis.  In addition, people and companies that are interested in scientific innovation might look for other opportunities rather than developing the next drug or device to improve care.  This won’t happen immediately but will erode what we value about our flawed system over the long term. 

There are, of course, many more arguments that can be made against universal healthcare and a single payer and there have been much more expert articles written on this topic than mine.  My point is that if we want to do something meaningful regarding the health and wellbeing of our fellow Americans, we need to stop kicking around healthcare like a populist football.  Whether it is the left advocating for universal coverage that is too costly and not supported by many who are happy with their coverage or the right who want to tear down any government supported safety net, the arguments being made are talking points and not real solutions.  I don’t have an easy solution but I do have thoughts that I want to summarize.  I believe our government’s best efforts are placed not in being the sole payer of healthcare (through our tax dollars) but by finding solutions that address the social determinants that negatively impact health especially for those who are most vulnerable in our society.  These issues impact everyone regardless of political identity.  Second, while the Affordable Care Act is flawed, it has encouraged stakeholders to innovate in how we care for populations.  This is also true for Medicaid expansion where states like Michigan have demonstrated real outcomes benefits for their programs.  Shifting the discussion from the federal government to the state and local level could allow for solutions that meet the unique needs of local populations by people who are more directly accountable to their constituents.  I would argue that we need to “double down” on aspects of our healthcare delivery that encourage innovation both to improve the value of the care we currently deliver and identify better ways to work together to deliver it for the future. 

I know my argument is flawed so please share your feelings with me and those reading this.  I hope I can stimulate a meaningful discussion on how to deliver better health for all of us and not people sticking to political talking points.  Thank you.