Nobody Comes to Work to Do a Bad Job…

by Mary Brandt, MD

“She’s really impossible… one of the grumpiest people I’ve ever met. We’ve had nurses come back from escorting patients to her almost in tears… if I worked with her, I’d be reporting her on a daily basis.”

I really, truly believe that there’s not a single person who gets up in the morning, looks in the mirror and says “How can I go to work to do a bad job today?” So what happens? Like the doctor described above, what happens to people that puts them in such a negative frame of mind? There are probably a few real jerks out there – maybe even some with real problems (like a borderline personality disorder). There is literature on disruptive physicians and some of this I’ll address in other posts (substance abuse, depression, compassion fatigue). For now, just consider the idea that most people who misbehave at work have something else going on.

It’s a lot easier to put up with negativity (and even downright rudeness) when you are rested. When you are exhausted, it’s just a lot harder. I think the key is recognizing that being tired makes you vulnerable to act in ways that aren’t “normal” for you…. and then consciously thinking about how to handle it. Here’s a few things to think about as you are taking a deep breath (or two or three..)

1. Don’t fall to their level. Whatever you do – look cool.

2. Don’t respond at all if tempers are hot. Let silence have a minute to work.

3. Try to consciously find a sense of compassion for them. What if their spouse just left them? What if they just got called on the carpet by their program director or chairman? It’s not an excuse – because really bad behavior is never the right answer – but maybe there are some extenuating circumstances.

4. Be personal… in a good way. Watch for an opportunity to discuss last nights football/baseball/basketball/hockey game, or the latest election, or anything that is not related to work. Learn people’s names, ask where they are from, etc. Humor is an important tool, if the opportunity arises and the other person is receptive. Anything you can do to befriend the other person will help – If you are able to develop relationships it’s harder for meltdowns to occur.

5. If it gets out of control you can always – politely and sincerely – walk away with “I’m so sorry you are having a tough day. I hope it gets better for you.”

This post originally appeared May 9, 2010 on Dr. Brandt's website Wellness Rounds

~~~

Mary L. Brandt, M.D. is a professor of Surgery, Pediatrics, and Medical Ethics at Baylor College of Medicine and a practicing pediatric surgeon at Texas Children’s Hospital. She is involved in education on a day-to-day basis in her clinical work. She also thinks about medical education on a bigger scale through her work as Vice Chair of Education of the Michael E. DeBakey Department of Surgery and Associate Dean of Student Affairs at Baylor College of Medicine. She actively blogs and tweets.

Compassion: Lessons from Roshi Joan Halifax

by Mary Brandt, MD

It’s not often that a talk completely changes the way I think about something.

I’ve been thinking and speaking about compassion fatigue for many years. I recently had the privilege of hearing a wonderful talk by Roshi Joan Halifax. She made a strong and convincing case that “compassion fatigue” is a misnomer… and that we should think about this in a very different way.

We can never have too much compassion nor can true compassion result in fatigue. 


Photo credit

Empathy and compassion are not the same thing.

Empathy is a necessary prerequisite for compassion, but compassion goes beyond empathy. Empathy is the ability to be with someone who is suffering, to be able to feel what they are feeling. Compassion, on the other hand, is being for someone who is suffering, being moved to act and find a way to relieve their suffering.



Link to Roshi Joan Halifax TED talk “Compassion and the true meaning of empathy”

Self-regulation is the key to being able to remain compassionate and this skill can be taught.
We all respond to situations of suffering with “arousal”, a state that varies in intensity depending on the severity of the suffering, and our own memories and experiences. How you respond to this state determines whether you can stay present, effective and compassionate. Roshi Joan Halifax offered the mnemonic “GRACE” as a way to teach this skill to medical students, residents, physicians, nurses and other health care professionals.

G: Gather your attention. Take three deep breaths. Be present.

R: Recall your intention. We choose careers in medicine to help heal the sick and to reduce suffering. It’s not easy to remember this intention when we are overwhelmed. But, in the moment we are faced with a human being who is suffering, we must let our own response (and the demands of the day) go and remember why we are here.

A: Attend to yourself. Being able to detect what is going on in your own body is the same “wiring” you use when you feel empathy. After gathering your attention and recalling your intention, pay attention to what is going on in your body. Watch your breath, feel where there is tension, pay attention to sensations.

C: Consider what will really serve. Moving from empathy to compassion is defined by considering the actions that will relieve suffering. Really consider the person and the situation and decide what is most likely to improve the situation.

E: Engage ethically.

“Developing our capacity for compassion makes it possible for us to help others in a more skillful and effective way. And compassion helps us as well.” Joan Halifax



Photo credit

This post originally appeared January 13, 2014 on Dr. Brandt's website Wellness Rounds

~~~

Mary L. Brandt, M.D. is a professor of Surgery, Pediatrics, and Medical Ethics at Baylor College of Medicine and a practicing pediatric surgeon at Texas Children’s Hospital. She is involved in education on a day-to-day basis in her clinical work. She also thinks about medical education on a bigger scale through her work as Vice Chair of Education of the Michael E. DeBakey Department of Surgery and Associate Dean of Student Affairs at Baylor College of Medicine. She actively blogs and tweets.

A bit of kindness

by Amalia Cochran, MD

The following is an excerpt from an email I recently received from a mentee:

“I love, love, love surgery, but even as someone who has thrived in this environment, I now acknowledge that there are some aspects of the culture of surgery/academics/surgical and medical education that I am deeply unsettled by and wish very much to change. I see fellow students, residents, fellows, young faculty transform from being full of zeal and goodwill into angry, bitter, jaded people, and it’s absolutely disheartening to see. What’s more infuriating (to me because of the wrongness of it all and because I’m such a fixer) is that those who have been negatively affected and are the very ones capable of enacting positive change because they’ve “been there” sadly become the very ones who perpetuate the indignities of the broken culture, and they don’t even recognize that they’re doing so.”

Her important question that she asked me, and one that I found incredibly wise, was, “Did you ever struggle with this during your training or see this among your colleagues? Or even now?”

I asked her if I could answer this on the blog, and she graciously said yes. It was important for me to do so because I feel obliged to make some confessions related to her concerns.

The biggest one? I had many days during my residency when I was so tired, so broken, so frustrated that I wasn’t a nice person. While I was able to focus on doing the right thing for my patients, I could be and often was impatient with students who needed nurturing and staff who were still learning too. I was so Hell-bent on my own survival, on not making mistakes, on not showing any shred of evidence that I might not be able to succeed as a surgeon that I had no qualms about running over people. I nearly quit surgical residency during my PGY2 year because I didn’t like what I was my self becoming (then was nurtured by some VERY kind mentors who managed to help me hang in there).

I attribute a significant portion of my behaviors when they weren’t outstanding to sleep deprivation and not having a functional set of skills for coping with my chronic exhaustion. I also attribute some of my less-than-ideal behaviors to the surgical culture in which we were supposed to prove that we’re tough and don’t have flaws. Reality check: I may be resilient- I far prefer that word to “tough”- but I do have flaws. Sometime around my 40th birthday, I became okay with that.

• I want to believe I was asked about this topic because I’m seen as someone who is generally patient and supportive. A few key lessons have helped me get back to this place, one in which I think I existed prior to my 7 years of complete exhaustion and chronic stress.
• We’re all struggling. Every one of us is, in one way or another. That’s not a source of shame, it’s a source of humanity.
• If those moments in which your lesser self shows up are rare, people believe you when you apologize for your behavior.
• We are all learning, ever hour of every day. That’s what we’re here to do in a teaching environment.
• As someone in a position of leadership, my team and those around my team rely on me to set a tone. I don’t want that tone to be one of nastiness, blaming, and negativity because I want/ need a high-achieving team. Therefore, it’s up to me to be supportive, to be patient, to take a deep breath before reacting, even when my gut wants to say, “WHAT were you thinking?!?”
• When people are intimidated, their ability to think critically is impaired. Working in an ICU, I need everyone around me to be a critical thinker. Kindness does much more towards that end than bullying.
• If all else fails, go for a walk with the dog. Dogs are masters of this moment being the very best moment ever and that influence is contagious- particularly on a snowy day if one has a Siberian Husky in their life (as I do).

If nothing else I wrote tonight resonates with you, it’s my hope that a picture of an incredibly happy husky will help you pause and be a bit kinder.

This post originally appeared March 24, 2014 on Dr. Cochran's website Life in the Wild West

~~~

Dr. Amalia Cochran is Associate Professor of Surgery at the University of Utah.  She is heavily involved in undergraduate medical education, serving as the Surgery Clerkship Director and the Director for the Applied Anatomy track for 4th year medical students at the University of Utah.  Her research interests lie in surgical education and in clinical outcomes in burns.  She is completing her term as Vice President for the Association of Women Surgeons. 

Failure

by Mary Brandt, MD

Dear Dr. Brandt,
 
I enjoy your blog very much. As a second year medical student, I know that my peers and I all struggle with what we view as ‘failure’ at some point or another. I imagine this problem doesn’t stop (…ever), especially since medicine seems to attract people who hold themselves to extremely high, if not impossible, standards. If you’re looking for topics, I wonder if you might have some insight to offer on how to deal with the downfalls along the way.

Dear Colleague,

It is part of our profession that we will never stop trying to be perfect and – just as true – that we will always fall short. As a student, it tends to be about the tests you are taking and the feeling that you will never study enough. As a resident, it’s the feeling that you don’t know enough to make the decisions you are being asked to make. As a practicing physician, you will at times stay awake at night worrying about your decisions, even when you know you did the best you could. All of this sounds like a huge downside to the profession we’ve chosen, but it’s actually a blessing. One of the core personality traits of physicians is that they care. In a way, all of the stress about not doing well enough happens only because you have empathy and compassion for your patients.

Although it’s hard to believe at the beginning, with time you will realize that the feeling of having “failed” is actually a gift. You’ll discover that “mistakes” and, more importantly, “near misses” become your most valuable teachers. What’s important is that you grasp the opportunity to learn from falling short, rather than beating yourself up. “Failing” at a task (or test) is different than being a “failure.” When you have moments you feel you could have done better, use it as motivation to study a little more, go back to the textbook, look up one more article, or review all the facts again. William Osler, in his famous book to medical students (Osler’s Aequanimitas) talked about keeping a journal of mistakes: “Begin early to make a threefold category – clear cases, doubtful cases, mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth… It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. “

So, to answer your question about how to deal with the downfalls along the way - Start by revisiting your motivation. Remember why you started down this path in the first place. If you are trying your best to do the right thing, and are humble about the fact that you are human (and will therefore fall short) you can end every day with satisfaction and a sense of accomplishment. That being said, make sure that you work with focus – that when you study or work it is with dedication to the patients and families who are trusting you with some of the most precious decisions of their life. When you fall short, use it as motivation to learn. But, in this process, make sure you are taking care of yourself by taking time for good nutrition, exercise, social interactions and spiritual growth. The worst thing you can do when you feel inadequate is to just work more and more. This leads inevitably to compassion fatigue, which makes you less effective (and will make you suffer). Compassion fatigue is a common diagnosis for care-givers; it happens to every medical student, resident or physician at some point in time. Just like any other diagnosis, the next step is treatment. In a nutshell, the treatment is self-care. Here are few sites that can help you with tips to prevent and treat compassion fatigue:

Top 12 Self-Care tips

Preventing Compassion Fatigue

Do’s and Don’ts of Compassion fatigue

This post originally appeared November 13, 2010 on Dr. Brandt's website Wellness Rounds

~~~

Mary L. Brandt, M.D. is a professor of Surgery, Pediatrics, and Medical Ethics at Baylor College of Medicine and a practicing pediatric surgeon at Texas Children’s Hospital. She is involved in education on a day-to-day basis in her clinical work. She also thinks about medical education on a bigger scale through her work as Vice Chair of Education of the Michael E. DeBakey Department of Surgery and Associate Dean of Student Affairs at Baylor College of Medicine. She actively blogs and tweets.

I sought professional help.

By Stephanie Bonne, MD

When I finished my training, my husband and I were overwhelmed by decisions - student loans, college planning, life insurance, oh my! So, we decided to seek the help of a financial advisor. It's definitely been one of the better decisions we have made.  To address financial planning this month, I decided to interview my financial advisor, Robert Balice of Bridgewater Asset Management, and the answers to my questions are below.

Q: Many people say, “I'm finishing training, so I’ll just quickly pay down my student loans and max out my 401k.  What do I need a financial advisor for?”

A:  Some people don't need one, but I cannot think of a case when an advisor would not provide significant benefit to someone, particularly someone just starting out. When you are starting out, you need to have some perspective of where you are going.  Set goals, then focus on what you do well (surgery), while having an advisor guide you through the rest can help you take advantage of the opportunities available to you, and help you miss some of the pitfalls on the way.  Even simply establishing an investment strategy for your 401(k) is fraught with pitfalls. 

Q: Okay, so I think I need an advisor. How do financial advisors get paid?

A: Good advice is not free, but it is important to understand how an advisor is compensated to make a choice that fits your situation.  There are 2 predominant ways:

1. Commissions – The advisor makes a commission on the products they sell you (insurance policies or investments).  This can work if you don’t need long term advice, like managing a one-time inheritance.  However, beware of implication that you don't pay anything for the investments they place you in simply because you don’t “see” the charge.  There may be up front, ongoing or back end sales charges. It may appear that you are not paying anything, but the advisor is definitely making something by recommending a certain investment or insurance product.

2. Advisory fees - for the vast majority of people, you want your advisor to be compensated in a way that he/she is motivated to keep your interests first, and stay engaged over the long term.  A fee-based advisor is not getting transactional compensation up front by selling products, they make money on your business over time, so it is in the interest of the advisor to keep you as a long term client and make sure you continue to get advice on your investments. 

Either one can be right for any individual.  A fee-based advisor is a true consultant and not a salesperson.

Q: What’s the best way to address my student loans?

A:  There are a few strategies that apply to everyone.  Consolidate your loans to get lower interest rates, and try to get fixed rate loans in case interest rates rise.  Next, consider what you can make in your investments versus the interest on your loans to decide what to pay off. If you are paying 2.5% on your loans, don't rush to pay those off and forego savings where you can earn 5% and build an investment account.  Remember you can always liquidate your savings to pay the loan off in the future for some other reason. To contrast, if your student loan rates are 8% annually, you should pay those down, because it's hard to expect that your investments will make 8% annually after tax.

Q: I have little kids at home.  How much is college going to cost for them?

A: Most children of educated parents, certainly doctors, would expect that their children are going to attend college. You can pay for college by either saving for it with discounted dollars, or pay for it afterwards with loans that have additional interest costs.  I suggest that you not plan for financial aid.  The best way to plan is to start early, and save for a good 4 year university, either private or public.  A child born today will need about $200,000 for a 4-year degree at a public school, or up to 3 times that for private school.  To achieve this, you need to save $400-$1000 per child per month from your child's birth. It's hard to imagine that private schools will cost over half a million dollars, but that's just the reality.  However, college inflation was previously 6-7% annually, but has recently slowed.  Still, I'd plan for the worst and hope for the best.  

Q: Taxes are always a concern for those in higher income brackets.  How do I avoid taxes?

A: Start by taking full advantage of employer matching contributions through your qualified plan (401k, 403b). Today, many companies offer traditional pre-tax savings or after-tax investment savings as in a Roth 401(k).  If you are still in residency, you tend to be in a lower tax bracket, and at that point, you are better off using Roth 401k or Roth IRAs, because the taxes today are not as large as the taxes you will pay when you take that money out.  If you are out of residency and in a higher tax bracket, then you definitely want to use the pre-tax options so you get the tax benefit today.  You can control your taxes better in retirement by choosing how much income you are going to take, whereas you have less control now, as your income is decided by your employer. If you have outside income due to speaking engagements or consulting, you should consider opening a personal qualified plan for that income.  The tax code allows you to have multiple qualified plans as long as there is no common ownership with your employer.

After your retirement accounts, your tax deductions dwindle quickly.  If you are saving for your child's education, some 529 plans offer state income tax deductibility.  

After that, try minimizing taxes on the savings that you are making on an after-tax basis. These generate taxable income and capital gains.  Variable annuities or variable universal life policies can accomplish this, but consider all the pros and cons of these vehicles and the tax implications of such products.  Bottom line is: you can lose up to 1/3 of your investment earnings if you don’t pay attention to the tax treatment of your investments. .  Not all investments make sense for everyone - this is why you need a qualified advisor.

Q: I am concerned about an injury that causes a loss of my ability to do surgery.  How do I plan for this?

A: You’re right; statistically, you have a 40% chance of being disabled for 90 days or more before age 65. Your first line of protection is your employer’s group long term disability plan. However, be aware that it typically does not cover all your compensation; specifically, it may not cover your bonuses and will not cover any outside income. You may want a personal disability policy that overlaps the group coverage.  If you purchase options for future coverage, that guarantees your insurability as your income continues to go up.  If you plan on having your own practice, and therefore not working for an employer, then a personal disability policy is essential to do at a young age when you are healthy and costs are lower.  

Q:  Long term care insurance (LTCI) is getting more expensive and is of greater necessity for women than men.  How should we be prepared?

A: Because women statistically live longer than men, insurance companies have struggled to fully assess LTCI.  As a result, some states have recently taken away unisex rates for LTCI, resulting in up to 300% increases in rates for women, who use LTCI more and live longer.  Not all states have moved away from unisex rates, but they probably will at some time.  If you have any genetic conditions that would result in long term care needs (Parkinson’s, Alzheimer’s); then early coverage is essential.  

Q: What if I still live in a state with unisex rates?

A: If you are in a state that still has unisex rates, you should take advantage of some sort of coverage.  The premiums are not guaranteed, and all rates will go up as the demand for long term care increases. But, if you are in a unisex state, you would probably get a much better premium if you get a policy before your state changes. If your state changes later, your rate will probably be more than the unisex rate, but less than the female rate.

Q: Does long term care insurance follow you if you move?

A: Some employers have group long term care which are portable if you leave employment.  But, these tend to have limitations in coverage for things like in-home care. In that case, a personal long term care usually will provide more comprehensive coverage, and is portable if you change jobs. The timing of when you should acquire LTCI is based on many individual factors such as age and health.

Q:  Women typically have longer life spans.  What does this mean for financial planning?

A: We already addressed long term care.  The other challenge is to accumulate retirement assets.  If you live into your 90s, you may need to draw 30 years of income from your investments.  Longevity translates to a more aggressive savings strategy now. This does not necessary mean taking on more risk, but would require higher accumulation to meet their retirement needs. The advantage women have due to longevity is cheaper life insurance rates because insurance companies are less likely to have to pay your death benefit early.  What that means in terms of financial planning is that we can consider insurance-oriented products to provide sources of retirement income with relatively low insurance costs.

Q: I hear a lot about the debt accrual by the US Government, what does this mean to me?

A: This isn't meant to be political, but the fact is, the government has a lot of debt.   In the intermediate and long term, having so much debt is likely to translate to higher inflation and higher taxes.  This requires your retirement savings to outpace inflation, in particular.  In the short term, interest rates will likely need to increase. This means you should be aware of the impact of rising interest rates, in particular to fixed income investments.

~~~

Robert Balice is a full-service financial advisor at Bridgewater Asset Management in Chesterfield, MO.   He completed his undergraduate education at Lawrence Technological Institute in Michigan, and has an MBA from Washington University in St. Louis.  He has over 20 year experience in financial planning. www.bwam.net

 Stephanie Bonne is an assistant professor in trauma, acute and critical care surgery at Washington University in St. Louis. 

Creating your own academic timeline

by Christina Cellini, MD, FACS, FASCRS

This topic came to me during a grand rounds given by a well-known surgeon in his mid-career - henceforth will be referred to as “WKS”. I had just returned from my second three-month maternity leave in two years and was looking forward to hearing about what advice he had to give.

That morning WKS gave a talk about how he advanced academically starting from residency to his early attending years that eventually led to his promotion to associate professor. His talk was very informative, and he made a really big deal about being present for your family while trying to achieve your goals. All in all it was a thoughtful presentation. However a few things caught my attention and highlighted how everyone’s situation is unique.

One piece of advice given was that one should constantly “be writing papers” and even to “get up at 4 am before work” to write in order to fulfill that goal.

4am??? I thought back to what I was doing at four A.M. that morning. Oh right… I was nursing an infant. I’m certain that’s not something that ever stood in his way of writing papers. Oh well, no time for paper writing this morning. Maybe tomorrow.

His next piece of advice was to take advantage of all the wonderful scholarships and traveling opportunities that are catered towards young attendings under the age of 45 . He showed lovely pictures of him and his family frolicking around a foreign country that was many time zones away.

I thought- wow! I didn’t know about these awards. I should think of putting something together. Then I thought of the logistics- I don’t think I’ll be able to leave my tiny children away for that amount of time. And since these days I need to plan about an hour in advance to take both kids out to a trip to Target…. maybe in about 5-7 more years. But then I’ll be too old for these scholarships!

Finally he mentioned being involved in society meetings and to bring family along so that you can take advantages of the opportunities there while your spouse and kids go and do fun things in the area. See- you can work and spend time with your family as well! I thought- that might be doable. I did have to skip the last 2 of my society meetings because I was either too pregnant to fly safely or did not have the resources to travel with an infant. Let me ask my husband how he’d feel about watching the girls in a strange place for a week while I do my surgery thing. I texted him- I got back “absolutely not”. Apparently dealing with two cranky, nap-less, off schedule children by himself while I do my own thing most of the day was not my husband’s idea of “family fun”. He encouraged me to go alone. Now don’t get me wrong- my husband is awesome and takes care of the lion’s share of child rearing and is supportive of my career- but I couldn’t blame him for not wanting to sign up for that.

WKS had a number of great ideas that worked for him to achieve academic success so quickly in his career. I am certain there are many young surgeons - both men and women- who can achieve that as well. However, WKS had a personal situation that allowed him to flourish early on. He was able to follow the typical academic timeline that usually consists of publishing 2-3 papers/year, obtaining some sort of early career development grant or funding in the first 5 years as a means for future funding, active involvement in the ACS and specialty societies - all in addition to growing one’s clinical practice at the expected pace. With this timeline one can usually expect promotion to associate professor within five years or so. I know that I will not be able to keep up with that timeline. My path to promotion will likely take a few (or more) years longer than others. Occasionally I get antsy about it when I perceive that my peers are advancing faster than me or that I am in some way “behind”. However, I have been lucky to have colleagues and mentors that understand my need to slow down for my family and are supportive of an “extended” academic timeline to academic advancement.

Now, if you can breastfeed and write scientific papers at the same time go for it! If not, I suggest the following:

1) Take some time to really think about what your future academic goals are. Make them very discrete, not ambiguous. Also, take the time to write them down.

2) Prioritize the goals and create a timeline to go with them. Give some real thought as to how you might go about achieving these goals. Again, the more specific you are, the more likely you are to realize them.

3) Share your academic timeline with a more senior colleague or mentor. Doing so may help you identify potential opportunities or pitfalls in your strategy that you may not have considered. As always AWS members are available to help- and have likely been in your shoes at one time or another!

4) Periodically look back on what you have written and adjust as necessary. Do not feel bad or guilty if it takes longer than you thought. Try not to fall into the “keeping up with the Jones’s” trap that can be prevalent in surgery (I know I have on more than one occasion). Take the time to write down and reflect on everything that you have accomplished up to that point. Remember no accomplishment is too small! As long as you remember what’s important to you and keep your eye on the prize you will no doubt be able to balance your personal and professional life and accomplish what you have set out to do.

Readers, how have you adjusted your own professional timeline to achieve both personal and professional goals in a reasonable manner? Share your thoughts below.
 

~~~

 

Dr. Christina Cellini is an Assistant Professor of Surgery and Oncology at the University of Rochester Medical Center in the Division of Colorectal Surgery. After obtaining her undergraduate and medical school degrees at Cornell University she trained in general surgery at the NewYork Presbyterian Hospital-Weill Cornell Medical Center. Following residency, she completed a fellowship in Colorectal Surgery at Washington University in St. Louis. She recently completed a Masters in Medical Management at the Simon School of Business at the University of Rochester. She lives in Webster, NY with her husband and 2 children and enjoys running and snowshoeing in her free time. Dr. Cellini serves on the AWS communication committee.

How I Make It Work

by Danielle Walsh, MD

December is the time of year when the constant struggle between the needs of work and the commitment to family become most strained. Holiday performances at school, parties for kids sports and other organizations pop up, work-related celebrations occur, and both of my children celebrate birthdays within a week of Christmas Day. After a long day of operating you try and shop online or in crowded stores before heading home to make dinner, ensure homework is done, and then proceed to whatever holiday event is scheduled for that night. It’s exhausting. But I can’t imagine it any other way.

People always ask how to make it all work. Lately, my response is more refined than in the past and it utilizes the tried and true analogy of the full bucket. You have to start with the biggest rocks. My kids’ birthdays, gymnastics meets, the annual AWS conference and a few other events are rocks. They are unmovable, non-negotiable events on my calendar. These are my biggest rocks. My OR days are Monday and Friday. My clinic days are Tuesday afternoon and Thursday morning. They are not movable and are the next size down rocks. I schedule a date night with my husband at least twice a month. Still a rock, but can fit around the other stuff. Then everything else gets filled in order of priority like the AWS, work on a grant, student and resident teaching – gravel, then sand, then water. Most of the time I try to leave pockets in “reserve” – an hour in my schedule for the gym, prayer, or just walking through a store undisturbed (my husband calls this retail therapy, even if I don’t buy anything). Often this is when I can review what the priorities are for that day or week to determine what goes in the bucket.

Sometimes the bucket overflows. I try to do too much at the same time or something unexpected causes the balance to tip. Then I call in the backup buckets – my husband, my parents, my partners, or some hired hand to take on what I can’t handle. Occasionally it means a paper is late (not unlike this blog, which I had hoped to write last week), emails get left in the inbox, and phone messages are not promptly returned. These times never feel good. I hate not being able to do it all on time. Some of the dislike is frustration of leaving others hanging, waiting for me to take action. Some of the issue is realizing that I made an error in taking on so much. But it serves a purpose – a reminder to be patient with others, accept imperfection, and continue trying to do better.

I always schedule at least some vacation time in December when the kids are off. The first day is set aside to clear out all the late assignments from work (like this blog) that will keep me giving my family my full focus. And then I sign out to my partners, turn off the beeper, set up the auto-reply for work email, and be just a mom, wife, and daughter to family for a while. It always feels good.

So as 2013 draws to a close, take a look at your bucket. What are the rocks, the stones, the pebbles, sand, and water? What can fit where and when? Find your time for work, time for family or friends, and time for yourself. May your bucket be full and satisfying.

Peace to all.

Danielle Walsh

P.S. – Didn’t get around to Christmas cards yet. Might still try to do them, but don’t hold it against me if they arrive a little late.

~~~

Dr. Danielle Walsh is an Associate Professor of Surgery at East Carolina University in the Division of Pediatric Surgery. After obtaining her undergraduate degree at Columbia College and her medical degree from the University of South Florida College of Medicine, she trained in general surgery at Massachusetts General Hospital in Boston. She also completed a fellowship in fetal surgery and research at Children’s Hospital of Philadelphia and a fellowship in pediatric surgery at Children’s National Medical Center in Washington, D.C. She practiced in Jacksonville, FL holding faculty appointments at the Mayo Medical Center and University of Florida before moving to her current position in North Carolina. She is the 2013-14 President of the Association of Women Surgeons and mother of 2 children.

Pregnancy during Medical School & Residency

by Callie Thompson, MD

I have read a lot of discussions about “the right time” to have a baby during a career in medicine and most of them come to the conclusion that there is no right time. I don’t think that is really accurate. The more correct answer would be that the right time is entirely dependent on you and your situation. I feel well prepared to write this blog and give this advice because I have been pregnant during both medical school and residency (twice).

In chronological order, I will start with pregnancy during medical school. The first two years of medical school are typically spent listening to a lot of lectures and studying almost all of the time. The third year is usually heavy with clinical work and spending a lot of time in the hospital. And the fourth year is usually a few sub-internships and a lot of light rotations at your home institution. So, where would a pregnancy, birth, and caring for an infant fit in there? Again, it really depends on your situation. You have to weigh the physically demanding state of gravidity with what you will need to be doing at that time. If you are concerned about being on your feet all day, then maybe being pregnant in the first two years would work best for you. You also have to take into account the demands of a newborn/infant. If you need a lot of time to study or are not great at multitasking, then having a newborn prior to taking your USMLE Step 1 might not be the best idea for you. No matter what you decide, you must have a viable option for childcare in mind. I suggest that you do this prior to even becoming pregnant because you will need help.

Regarding taking time away from school, there are no universal rules as to how much time can be taken. This will be school dependent. You just need to make sure that you can fulfill the requirements to earn your degree. Some people choose to take an extra year and make medical school a total of five years to allow them to have their child. I do not think this is necessary for everyone and you are going to know your capabilities best. Don’t let someone push you into a 5th year just because others before you have chosen to do that.

Pregnancy in residency is a bit trickier because of the American Board of Surgery requirements for General Surgery Certification. I had a baby during clinical R3 year and another while I was out in the lab. From a time-off perspective, having a baby during your lab years is much easier. If you are NIH funded through a training grant you can have 6-8 weeks, though some lab work can be done from home so the actual time you get to spend with your newborn can actually be longer than that depending on your research. Having a baby during your clinical years requires a good understanding of “the rules.” The ABS states that:

“To be eligible for ABS certification in general surgery, the following must be completed: At least 48 weeks of full-time clinical activity in each residency year, regardless of the amount of operative experience obtained. The 48 weeks may be averaged over the first three years of residency, for a total of 144 weeks required, and over the last two years, for a total of 96 weeks required."

“For documented medical problems or maternity leave, residents may take an additional two weeks off during the first three years of residency, for a total of 142 weeks required in the first three years of training, and an additional two weeks off during the last two years of residency, for a total of 94 weeks required in the last two years of training.”

Translation: You can average your time over the first three years so, in theory, if you didn't take any other time off for three years, you could have a 14 week maternity leave. Similarly, if you didn't take any time off for vacation during your last two years, you could have a 10 week maternity leave.

In actuality, that isn't possible. For instance, you would have to know that you were going to get pregnant and have a baby during third year so that you could forgo a vacation in your first 2 years. And if you did that, you would surely go insane. So if you did take the regular 3 weeks of vacation a year, you could have an 8 week maternity leave during the year you did have the baby—as long as you don’t take any other vacation that year. A baby during the last two years is even more difficult because of the time constraints. Also, keep in mind that none of this accounts for the possibility of medical problems during the pregnancy and any time off that may need to be taken. None of this is meant to dissuade you from pregnancy during residency (see above where I state I did it twice) but knowledge is power and you have to be prepared to extend your training if you are unable to meet the ABS requirements. This is most important during the last 2 years because they have to be done in succession so if you were to get pregnant, become ill, and need extra time off during your 4th or 5th year, you may be required to start over at year 4.

This blog could end up being very long so the last topic that I will include for today is when/how to tell people when you become pregnant. I advocate telling people when you feel comfortable. For some people that is the minute you find out, for others it is after the first trimester. However, I would not wait much beyond the first trimester because arrangements will need to be made, either to your schedule if you are a student or for coverage from your co-residents if you are a resident. I also would also advise you not to tell anyone else before you tell your Dean or medical school adviser (for students) or your program director (for residents). It is best to give big, personal news yourself, and in person.

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Callie is a resident in general surgery at the University of Washington. She completed a two-year research fellowship and is now in her fourth clinical year.  Callie aspires to be a burn and trauma surgeon and a translational scientist. Her research interests include genetic variations and their associations with the development and outcomes of disease and illness. Callie is married to an internist and has three children under the age of 7.
 

“The Advice Less Given”

by Stephanie Bonne, MD

As a relatively new mother (I have 2 boys, ages 3 and 1), I’m usually anti-advice. I often feel as if each person’s situation is unique and resources and priorities are variable, so it’s hard for anyone to give meaningful advice that fully applies to me. If you have a young family or are contemplating having a family, you have no doubt been inundated with advice from lots of very well-meaning people. Some advice is trivial (“Jen is the best Gymboree instructor!”) and some is not (“if you are going to have more than one, make sure you have them as close together/far apart as possible”), but much of it we hear over and over again. “There is no good time,” “make sure you have lots of help,” “remember to take time for yourself,” are all well-meaning, but tend to be a little vague and can mean vastly different things to different people. However, in recent months, I’ve gotten 3 pieces of parenting advice that were a bit different than the usual advice and pretty adaptable to most woman surgeons, so I thought I’d take the opportunity to share them here.

1. “Learn to let go of some stuff, but not ALL stuff.” This is a comment on balance. As a surgeon, I’m used to being in control of almost everything, but as a parent, I can’t be. This first became apparent to me when my son came home from daycare one day in a mismatched outfit my husband had put him in that morning after I had left for work. I suppressed the urge to say “You let him go to school wearing THAT?!” Having meticulously dressed children is just something I have to let go of, along with the occasional glass of non-organic milk, or extra half hour of cartoons. My first advice to young moms: Throw away the Pottery Barn Kids catalog the minute it enters your house. No four year old boy spends an afternoon quietly reclining in his sailboat-decorated bedroom, reading a Caldecott-winning book while snacking on a perfectly balanced meal from his personalized bento box (seriously, when did preschoolers start carrying bento boxes?). Now, that last statement might sound remarkably reminiscent of some jaded-but-funny suburban parenting blogs. My second bit of advice: unsubscribe from these too. True, there may be humor in highlighting all your first-world failings as a parent, or brazenly point out that your kids are still alive, in spite of your best efforts and constant feelings of failure. These blogs, however, in an attempt to use intellect to deescalate the “Pottery Barn” ideal of a perfect mom, somehow miss the mark and instead validate the very thing they are trying to dismiss. You are a surgeon; you don’t have time to get involved in the mommy wars. This means letting go of the things that don’t matter, but realizing that not everything can be marginalized, and recognizing which things do matter. Your kids need to be fed, clothed, washed, and most of all loved, but that’s just the start – they DO need intellectual stimulation, bedtime stories, play time, social interaction, and swimming lessons. You can’t cast these things off as insignificant in the life of a child, but you also don’t have the time to place too much importance on each of your child’s experiences being perfectly orchestrated to be both stimulating and meaningful. Balance.
2. “Teach your kids, right from the start, about what you do and why it is important.” My experience with this has been short so far, but I do tell my son when I leave for call that I have to go to the hospital to help take care of sick people. Naturally, after a few times, he mustered a fake little cough and said “but I’m sick too.” I think every doctor-parent has a story like this, and yes, it is heartbreaking. But my husband and I reinforce what I do and why it is important and I think my son does understand. He will ask me when I come home the next day if I fixed the hole in someone’s tummy, and burst out an encouraging “great job, mommy!” when I say yes. When I recently went to DC for the AWS and ACS meetings, he asked me if people in Washington DC have holes in their tummies too. I’m sure the day is coming when I will miss a big soccer game or first music recital, but knowing that they understand what I do will help them. Sometimes, reminding myself of the importance of my work helps me too. 
3. “Take time for you and your partner, and do it guilt-free.” This is a variation on the date-night advice, but the key here is doing it guilt-free. This came up last spring after my parents were graciously willing to watch the kids for a few days so my husband and I could have a little getaway. Afterwards, I was recounting our trip on two separate occasions to some older, wiser women when they pointed out that I was making excuses for why we didn’t take the kids on our trip. Both encouraged me to never feel guilty for the time I spend away from the kids, pointing out that having two parents who live together, and furthermore, love each other, is far more important to them than the couple of days spent away from us. I think there is balance here too – we can’t jet away together every weekend, but we can do it within reason and should do it from time to time. For different couples, this will look different – to some, it’s going on long walks or runs together, for others it’s a monthly date night, for others it’s a weekend away once a year. Whatever it is, it’s helping you stay together, so make it a priority, but the real point is - don’t feel bad about it.

Props to the awesome women who gave me this advice – some of you will be reading this, and you know who you are. For the rest of us, take the advice that is given to you gracefully – remember, advice is rarely given in a malicious spirit, and most of your advice-givers really do have your best interest at heart. But take each piece and either toss it later, or process it and make it fit for you, and if it’s really good, pass it on later.

~~~

Stephanie Bonne is an Assistant Professor in Trauma, Acute, and Critical Care Surgery at Washington University in St. Louis. Her husband, Jeremy, is a trademark attorney for Anheuser-Busch. She has two sons, Evan, 3, and Colin, 1.

Family Life

by Jennifer Knight, MD, FACS

I picked this topic because for me, Family Life is a work in progress and sometimes putting thought into something you are working on often allows for enlightenment. As a surgeon, the idea of work life balance is a moving target. I struggle with it most days, but recently a colleague of mine told me that they wished that they could master the work life balance like I had. Master seemed a strong word!  There are things I have mastered; work life balance is not one of them. But I think because I do “try” perhaps that’s as close to mastering, as I will get. I though maybe I’d list a few things that I do as my attempt to try.

1. You need a team. A friend, who is not a surgeon, pointed out to me that I need a team of people in the operating room to ensure that my cases go smoothly and efficiently. Why didn’t I have the same type of team for home? Would a team help my home run smoothly and efficiently as well? So I got a team! I already had a nanny but added someone to clean by house, I signed up for after school play dates, and developed an arrangement with a caterer for parties and functions. 
2. Facebook. Everyone has an opinion about personal pages on Facebook. I find that I can use Facebook to stay involved with friends and relatives. I can post pictures of my family and send birthday wishes to friends. When I am able to meet face to face, I don’t need to “catch up” as much.  And while I am a peripheral user, a select “like” or “comment” lets other people know I am still around and care.
3. Plan ahead. I clearly communicate to everyone that if they want me to participate, I need 3-6 months advance notice. I’ve been able to go on class trips with my son, plan weekend get-away with girlfriends, and make most birthday parties. My friends have commented that planning in advance has helped them be more organized as well.
4. Have a good partner. My husband is also a surgeon and has a high level administrative job in our hospital system. We have to have great communication about each other’s schedules. But he is equal parent. He likes doing laundry and I like yard work. We complement each other’s strengths and weaknesses and both give 100%.
5. Mow the grass. Maybe not literally. But I love mowing the grass. And while I have a “team”, the one job around the house that I love is mowing grass. I put on my headphones and put my John Deere into drive and have great personal quiet time attacking the lawn. The point is, make sure you have alone time and if that alone time contributes to the family in some way, even better.
6. Family-friendly and fun-friendly are two different things.  I have friends and work partners who are single. Make sure that your focus on family life doesn’t trump your friends or work partners needs or plans as well.  

This is not a perfect and complete list but each of these things have helped me. Your family life is YOUR family life. Make it what you want it to be.

What tips do you have that help balance your work life and your family life? 

~~~

Jennifer Knight, MD, FACS is an Assistant Professor of Surgery at West Virginia University. She serves on the AWS Communications Committee. 

Interview with Dr. Julie A. Freischlag

by Bharti Jasra, MD

A while back, there once was a little girl in Illinois who impressed everyone with her extraordinary performance at school. Her grandfather told her that when she grew up, people would tell her what she could or couldn't do. "There is nothing that I can't do," her grandfather said. "Is all you need to tell them all."

That little girl grew up to be the great vascular surgeon whom we know as Dr. Julie A. Freischlag. She is an internationally renowned expert in thoracic outlet syndrome. She became the first woman director of the Department of Surgery at Johns Hopkins in its 110 year history. She served as President of the Society of Vascular Surgery from 2012 to 2013. In 2012 she was elected Chair of the Board of Regents of the American College of Surgeons. In addition, she has held leadership positions in many leading surgical societies and serves on the editorial board of several surgical journals. In February 2014 she will join the University of California, Davis as Vice Chancellor for Human Health Sciences and Dean of the UC Davis School of Medicine.

I had the opportunity to interview this great leader and ask a few questions that I thought might benefit our Association of Women Surgeons members.

Q: What role did AWS play in your career?
A: I was one of the first few resident members of AWS. It was really nice at that time to know that there were other women in the surgical community that I could look up to for guidance. Also in early years of my career it helped me as a forum for networking. It was at AWS meetings that I met Dr. Patricia Numann for the first time, and we became good friends in the next 20 years.

Q: Do administrative positions adversely affect clinical duties?
A: I spend 60% of my time in departmental work and whereas only 40% in teaching and clinical duties. As a department chair one has to work for the department and not just for yourself.

Q: Is it essential to have additional degrees like an MBA to hold a leadership position?
A: It is not required to have additional degree but there are several leadership courses offered by ACS and AAMC which could be useful. I myself benefited from the ELAM course and highly recommend it.

Q: Do you think that you had a different set of challenges being a woman?
A: It's quite lonely up there at that level since there are not many of you. Women are underrepresented not just in medical community but in legal and business communities as well. It's easy to get noticed since there are not many of you at that level. At the same time it gives you a unique opportunity to represent interests of an underrepresented class and most effective use of this opportunity is essential.

Q: Do you wish you had more time to spend with your family?
A: I am blessed with a caring husband and loving children. As surgeons we like to stay busy and I have no regrets as I have been able to find time for my family for the most part. I try to go to my son's sporting events and recitals. Also I try to limit my travel for work as much as possible.

Dr. Fresichlag with her son and husband during Parents Day at the University of Maryland

Q: What is the key to happiness?
A: Staying in touch with yourself and your family is the key to happiness.

Q: What do you do to rejuvenate after work?
A: I am a swimmer and use the pool in our backyard. Also I walk try to walk few miles a day.

Q: What is your opinion on infertility among women in surgery?
A: I believe it has been a problem, but we are heading toward better times. My own residents now are having kids during residency, and it’s only going to get better in the future.

Dr. Freischlag with her family at the Ravens-Packers game   

Q: What challenges do you foresee in this new leadership role at UC Davis?

A: I am very excited to learn more about something other than surgery, especially healthcare delivery and medical education among the Hispanic population.

Q: Any message for AWS members?

A: We are very lucky to be surgeons, and we should enjoy every part of it at all levels, whether we are residents or in practice. 

~~~

Bharti Jasra, M.D. is a medical graduate from India finishing up her General Surgery Residency at Saint Louis University Hospital. She is interested in pursuing Breast Surgical Oncology training in the year 2014.

Shoes to Wear in the Hospital

by Mary L. Brandt, M.D.

I got home recently after a 14 hour day in the operating room with (predictably) a pair of really tired feet…. which lead me to think about shoes, foot rubs, and the fact that no one ever talked to me about this in my training.

What kind of shoes should you wear in the hospital?
 
There’s a lot of walking in the hospital, but there’s even more standing. Running shoes don’t provide the right kind of support for standing, which means your feet will suffer if that’s what you wear.

It goes without saying that you should not wear open toed shoes in the hospital. It’s not only against the rules, but it’s going to gross you out one day.

Basic concepts to choose good shoes for work in the hospital

• Look for good support. The classic “nursing” or “operating room” shoe exists for a reason – they are designed to provide the support your feet need during long days of standing and walking.

• If you are not in scrubs, you’ll still need OSHA compliant, comfortable shoes. They can be stylish, but make sure they fit the overall professional image you are trying to achieve. Check out San Antonio Shoes (SAS), Clarks, Rockport and Ecco.

• If you will be standing for long periods on rounds or in procedures, think about getting shoes that slip on and off. When you are standing for a long time, being able to slide out of your shoes becomes important. If you’ve been standing for hours it really helps to stretch your calves and change the pressure points. It’s also easier to step out of your shoes all together and stand barefoot for a little while. When you are sitting, you can slip them off and let your feet breathe. Dansko Professional clogs are expensive but are probably the best in this class. Sanita clogs are supposedly now made in the original Dansko factory. Birkenstock, Keen or Clarks clogs are good alternatives. Crocs are tempting but have poor support, minimal ventilation and have been banned in some hospitals.

• Try to get shoes that breathe. You can find shoes that are like clogs in their design, but are made of materials that breathe. Examples include Merrell’s Encore Breeze (my current personal preference). They are not only comfortable, but they can be put in the washing machine (minus the insoles) if they get really dirty at work.

• Once you’ve met those criteria, lighter is better.

• Cheaper is good, too. One lead from studentdoctor.net is footprints.com.

Long days standing at work also make for stinky feet. Just like long-distance runners, you have to learn some tricks to deal with this.

1. Have more than one pair of good shoes and alternate them.
2. Don’t buy cheap socks. Wicking socks like Balega socks are worth the price.
3. Take an extra pair of socks with you for long days and change them in the middle of the day.

Foot massage, pedicures, and other foot care

After work, in terms of “bang for the buck” there is nothing that will make you feel better than a little attention to your tired feet.

Use a good foot scrub in the bath or shower like Bath and Body Toe the Line of The Body Shop’s peppermint scrub .

Take 10 minutes and try some methods to soothe tired feet. If you are lucky enough to have a significant other who will rub your feet … congratulations! (and, by the way, it really is “true love”…)

Even if you are a guy – don’t blow off pedicures. If you’ve had one… you know. If you haven’t… try it before you decide.

Cross-posted on August 14, 2011 at wellnessrounds.org

What shoes do you wear around the hospital? How do you take care of yourself after being on your feet all day? We would love to know. Share with us in the comments below!

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Mary L. Brandt, M.D. is a professor of Surgery, Pediatrics, and Medical Ethics at Baylor College of Medicine and a practicing pediatric surgeon at Texas Children’s Hospital. She is involved in education on a day-to-day basis in her clinical work. She also thinks about medical education on a bigger scale through her work as Vice Chair of Education of the Michael E. DeBakey Department of Surgery and Associate Dean of Student Affairs at Baylor College of Medicine. She is an active participant in the blog-o-sphere and on Twitter.