citizensurgeon

Atomic Habits - A Book That Changed My Life

citizensurgeon (Erik Pearson) — Wed, 04 Jan 2023 20:25:29 GMT

"I can change my habits more effecti vely by aligning my identity with the habits I need, for example, I didn’t just want to start running to get in shape, I want to identify as a runner ."

One of the habits I’ve picked up over the last couple of years is consuming information. I hesitate to say reading because I get my information from reading paperbacks, reading kindle, listening to audiobooks and listening to podcasts.

Using the Libby app , which was a real game changer for the budget, I’m able to use my library card and check out all of the books I need, sometimes having to wait a bit but eventually getting the book or audiobook for my 21 days.

When I come across a book that I really enjoyed I’ll buy it.

I bought this one.

Today I’m going to share the book that changed my life this year and has been a game changer for getting healthy and building new powerful habits.

I read this book with the intention that I needed to change a few things in my life with respect to my health, I needed to be more active and adopt a healthier lifestyle. In this book you’ll quickly realize that almost all of our actions are guided by habits. James Clear gives structure to our behavior, guiding us on how to adopt new habits and break old habits by making micro adjustments…these micro adjustments he refers to as Atomic Habits.

I learned that I can change my habits more effectively by aligning my identity with the habits I need, for example, I didn’t just want to start running to get in shape, I want to identify as a runner.

Clear discusses how all habits, good or bad, have four common stages.

You have a cue that triggers an opportunity for an action followed by a craving of the satisfaction that an action will bring and then the response (action or habit) that elicits the change in behavior and finally the reward.

With several different examples provided by Clear I was able to change the cues in my life to develop the habits I wanted.

At least a few to start.

A Personal Example

For example, I wanted to do 50 pushups every day .

I needed a cue that I did every day to associate with the new behavior.

Every morning I turn on the coffee machine and while the cup of coffee is being poured I started doing the pushups. Within a few weeks the behavior became very natural but linking the pushups with the coffee was an easy change. This is an example of habit stacking, after I do (current habit) I will do (desired habit). It was an easy experiment and it made a difference so I started to take the book seriously.

Over and over again, Clear brings evidence and gives concrete examples about how you can develop powerful atomic habits.

This is a book I’ve listened to at least 3 times and I’ve read it taking notes and circling things at least twice. I refer to it again and again and I gift it to friends.

I highly recommend you grab this book, it will make a difference in your life by the giving you the tools you need to make the changes you’ve desired.

Your Goals are Nothing Compared to Your Systems

citizensurgeon (Erik Pearson) — Tue, 03 Jan 2023 20:39:50 GMT

"Early in my life my achievement was because I set a waypoint, identified the checkboxes that needed to be completed to get there and I started checking boxes."

I have always been goal oriented and I felt like this was always a good thing. Maybe I’m wrong. Why?

By my definition of success I’ve led a successful life. I have a beautiful family, I am present as a husband and a dad, I have the privilege of caring for children and their families as a pediatric surgeon, I’ve completed marathons and Ironman events, I’ve traveled the world, I’m in good health, in my opinion the list goes on.

Early in my life my achievement was because I set a waypoint, identified the checkboxes that needed to be completed to get there and I started checking boxes. For bigger goals I needed tighter boxes. If I couldn’t reach the next waypoint I made more boxes to celebrate smaller wins. I repeated this for every new goal whether that was matching in pediatric surgery or completing my first Ironman.

So what’s wrong with setting goals? Here are a few quotes that have had me thinking:

“Losers have goals. Winners have systems.”
“Goals determine your direction. Systems determine your progress.”
“If you do something every day, it’s a system. If you’re waiting to achieve it someday in the future, it’s a goal.”
“You do not rise to the level of your goals. You fail to the level of your system.”
“Goal oriented people exists in a constant state of failure or waiting for the goal. Systems people win every day just by sticking to their systems. The systems people tend to perform better and be happier.”

In Scott Adams book How to Fail at Anything and Still Win Big he shares life lessons about building systems, creating talent stacks, expecting failure, pivoting on ideas, seeking feedback, and embracing the magic of affirmations. Reading this book definitely reminded me of the lessons in Atomic Habits by James Clear about building habits around your identity. Instead of “completing the Boston Marathon” the lesson is “I want to be identified as a runner.”

So let’s get back to the systems and goals discussion because it’s one that I struggle with daily. Who are goals good for and who are systems good for? The broad answer is both are good for everyone. Goals set the waypoint and direction and systems increase the probability you’re going to get there.

In surgery this becomes applicable in a number of ways. For example, take the annual ABSITE exam, which I’ve written about in How to Crush the ABSITE . This is an exam that all general surgery residents take annually to prepare for the American Board of Surgery exams that follow training. It’s a sort of check in each year for both the resident and the training program.

If you want to crush the ABSITE it’s all well and good to make that a goal. Few can achieve this goal with a disorganized plot and mishmash of studying, reading, question review, etc.

The people who continually crush the ABSITE are residents who create an identity (I want to be identified as a competent and knowledgeable resident) and back up that identity with the daily habit of reading and focused question review. It is the rare resident who achieves this goal without creating these habits and systems and those residents likely have already found their identity and have systems..

One statement I’ve always come back to, even though it does generate frequent eyeball rolls is this…

“Study to be a great surgeon and the exams will take care of themselves.”

You can replace the words surgeon and exams with anything…

The same is true for basic surgical skills and I wrote about this in Know the Basics last week. I can set the goal of “I want to be a skilled surgeon” and go through resident training assuming that I’ll be a competent surgeon when it’s all said and done. Or, I can be intentional and deliberate about the habits that identify with competent surgeons and build those habits. These are simple things like developing basic skills or thinking and preparing for operations and in my experience training residents they represent the systems of only a precious few.

So am I wrong for being goal oriented? I think there are three difficulties with goals:

1.). How do you choose the size of the goal?

2.). How do you get there?

3.). What happens after you complete the goal?

I believe goals are necessary because humans are achievement oriented. It feels good to win, it feels good to achieve, achievement fuels progress.

Size of the Goal

Unfortunately, because goals are specific they are inherently inflexible and failure is proportional to the size of the goal. So for success and achievement, we set smaller goals. The difficulty is how to determine what goals are too big and what goals are too small.

For me, I can relate to this when I decided I wanted to complete an Ironman event for my 40th birthday. I felt Ironman was within reach and was just a big enough goal to stretch me to the point of discomfort. I didn’t feel that I needed a Sprint or Olympic triathlon under my belt as stepping stones. I read the book Can’t Hurt Me by David Goggins and I thought, I’m tough, I’ve got grit, this will be hard but I can do it. If my goal was to win Ironman in Kona, it’s likely that I would be quickly disillusioned trying to get the sub 3-hour run after the 112 mile bike. For me that goal would have been too big, too easy to fail.

The size of the goal is personal and my experience has taught me that when you start to become disillusioned, when you start to fail, when you start to lose sight of the end you’ve just set too big of a goal.

How do we get to a Goal?

In our progress toward a goal, failure is proportional to inconsistency. The more inconsistent we are in our practice toward the goal the less likely we’re going to achieve the goal. This is where atomic habits and systems thinking comes to play in a big way. By building habit stacks (James Clear) or talent stacks and top 25% skill sets (Scott Adams) we can align the goal with our identity and start making daily progress in a focused way. By not building habits we invite inconsistency and chaos which brings us both further from the waypoint and increases the chance of failure.

Few people can achieve audacious goals without systems and they should not be role models.

In Talent is Overrated we learned about deliberate practice and whether you’re an athlete, a high performing business leader or a comic, systems are everything.

After Goal Achievement

Finally, what happens after the goal is achieved? What happens after you reach your goal weight, what happens after you cross the finish line, what happens after you’ve graduated your fellowship program? In my opinion if you haven’t developed an identity, if you haven’t developed your systems, you will fall…not fail, fall. It gets to the question of why did you set a goal in the first place? Was is to just feel the weight or the medal around your neck or impress people with the certificate on the wall or was it for something? Why?

After we achieve goals we fall back to our baseline. If we developed strong habits it’s likely we’ll continue those habits to support our new identity. If we didn’t develop strong habits or a strong identity it’s likely our new behaviors will fall.

Wrapping this up I believe in both goals and systems. Systems without goals seem unsustainable. Personally I’m not going to swim, bike and run everyday in a disciplined and hard core way just to do it…that’s just me. Goals without systems lead to failure in most circumstances for most people.

Experiment with yourself on setting the size of your goal. If the goal is too big, set a smaller goal in the same direction. Ask yourself what habits need to happen to develop systems to achieve your goal. These habits will not only get you to the goal but they will carry you forward with the identity you’ve created.

Systems and goals.

What do you think?

Personal - My Fasting Journey

citizensurgeon (Erik Pearson) — Tue, 03 Jan 2023 20:29:02 GMT

"I felt more control over my day and over my body and despite being surrounded by snacks it felt good to be held accountable to my fasting calendar and to say 'No.'"

One week of fasting and here’s what happened…

If you read my post last week on fasting you’ll know that I had been feeling a little out of sorts and needed a bit of a ch ange. While I generally eat healthy and am active sweating it out on the peloton or peddling through the desert on my mountain bike, with a lot of recent visitors to the house I had a few weeks of too much indulgence.

The fast was a change to set me straight and with the Napa to Sonoma half marathon coming up in 2 weeks I needed it!

I’ll give you my method and a little data after one week of fasting. It’s not too impressive but I’m a fan of how fasting not only changes your body but your mind.

First I was looking for a free app and came across Sunrise Fast , a tool that made fasting really really easy. After dinner each night, usually 6-7p I would click the “start fast button” and my hourglass would appear. I’m right in the middle a my current 16h fast so here’s what the app looks like:

The running hourglass would give me a sense of accomplishment and usually get me through the rest of the day. Also I would receive a notification when I was halfway through the fast and again when one hour is left. Most days I completed a 16h fast and some days I ponied up and did a 18 hour fast. For the last week it looks something like this, the November 24th fast will come up when I finish around 10-11 this morning.

As for the data I’ll show you how my weight, BMI and body fat changed over the week. Small changes but in the right direction. Most importantly was my mood. I felt empowered by the fast, I felt more control over my day and over my body and despite being surrounded by snacks it felt good to be held accountable to my fasting calendar and to say “No.” To myself usually but infrequently out loud.

Here is my weight, BMI and body fat using my Innotech scale and the associated app which easily lets me see the data over days, weeks or months for everything from weight and BMI to body fat, water content, protein, bone mass, etc. I don’t know how accurate it is but it’s nice to have the data.

So the numbers are going in the right direction, I’ve lost a few pounds, my BMI is getting toward a healthier lever and so is my body fat. These are most likely changes associated with the drastic change in behavior but they are changes nonetheless. Other than fasting I didn’t change much else in my routine. I still was doing my morning peloton ride or a mountain bike ride out in Red Rock Canyon. My diet didn’t change appreciably but of course I wasn’t snacking for most of the day.

Here are the things that I learned:

Start Fasting Early – If I started fasting early it was easy. If I hit the button after dinner, before 7p than I would finish my 16h fast before 11a and my 18h fast before 1p. If we had a late night and didn’t start fasting by 10p now my 16h fast went to 2p and my 18h went to 4p and that was really tough for me.
Exercise Didn’t Make Me Sick or Jittery – I was worried that after my morning workout continuing the day and operating on an empty stomach would leave me sick jittery. But I continued my 2 morning cups of black coffee routine, one around 430a and one around 630a and it was fine, no shakes, no jitters.
It Feels Good to Feel Hungry – There was something so empowering about not snacking and saying no. I found myself drinking a lot more water, a surprising benefit of the fast and while I would usually snack on something between cases I would have a bottle of water and it was perfect.

Going forward I think at least the 16h fast will be a part of the daily habit and I’ll continue to watch the data and post an update in a month or so. I’ll most likely add in a few 18h fasts and may even try a 24h fast as a nice reset. I don’t think I’m ready for the three day fast or greater but it’s something I would consider.

If you’re interested in learning more about fasts definitely check out Dr. Peter Attia’s talk with Joe Rogan on the benefits of fasting .

What are you thoughts? Have you tried fasting? Are you willing to give it a try?

Match Advice for the International Medical Graduate

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 13:53:43 GMT

"What you should consider to cross the chasm from international medical student to successfully matched trainee in any specialt y"

As an International Medical Graduate (IMG) I matched to my dream specialty, you can too!

If you’re an International medical graduate (IMGs) you make up a significant portion of United States Healthcare providers yet you face significant hurdles when it comes to securing a training position. If you’re a US grad then you have an immediate advantage to matching to your specialty of choice though these tips and lessons may still be very helpful as you put together your story, your fan club and your application.

For the IMGs out there, as an international medical graduate, also known as a foreign medical graduate, you may feel like you’re up against a wall when looking to match into competitive specialties or even to secure a position at a top program in a relatively uncompetitive specialty.

Knowing what I know now, would I do it again?

I went to the Royal College of Surgeons Ireland and I would do it again in a heartbeat. It was the best educational decision I have made.

I’ve reflected on my experience as an international medical graduate and my discussions with colleagues who were educated abroad and trained in the United States across all specialties. Here I describe advice you may consider to help you cross the chasm from international medical student to a successfully matched trainee in any specialty.

Recommendation #1: Think Critically About Your Specialty of Choice Early…Time is Your Friend, especially for the International Medical Graduate

I remember the first days of medical school, you just want to survive. So much to read and learn…”God, just let me pass.”

Once you’ve swallowed that pill and those initial butterflies are behind you it’s time to think critically about your specialty of choice. Surgery or medicine? Of course the choice is harder than this, you may choose psychiatry or pediatrics or obstetrics or pathology and the list goes on.

Students that decided earlier had more time to develop themselves for a successful match.

For some specialties as an international medical graduate you don’t have the luxury to decide to be an orthopedic surgeon or a dermatologist at the last minute, these specialties are a difficult match for US grads. You can use time to develop relationships, write papers, ask some simple questions and find some simple answers.

Time gives you the opportunity to build your story

With that piece of advice I must also stress its opposite. Don’t jump into a specialty. If someone jumped into general surgery because they thought it was awesome but didn’t like the smell of poop or the sight of pus they would be in the wrong place. Medical school is beautiful because the experience gives you the opportunity to see it all, every rotation and every specialty. If there are specialties you’re interested in that didn’t make it on your short list of rotations do a sub-I in that specialty to gain exposure or ask the residents if you can round with their crew on a weekend.

Time gives you the opportunity to travel and get more exposure

Being an international medical graduate also gives you additional opportunities to work with doctors in different specialties in different healthcare systems in different parts of the world. The threshold for traveling to another country is lower and perhaps the network you already have built into the medical school will give you a ton of opportunities for exposure.

For example, I was fortunate to go to Pietermaritzburg. South Africa for a couple of months during the summer between my second and third year of medical school. I spent mornings and days with the neurology team and evenings with the surgery and trauma teams. It was an incredible experience to work with the people in that part of the world. The time and relationships opened my eyes to the incredibly powerful skillset that surgeons acquire over their training.

Recommendation #2: Do Well on the USMLE Step 1

Of course right? So easy! It’s unfortunate that The Match puts increasing emphasis on the USMLE Step 1; however, it does. Don’t live in denial, just study hard and do well.

I interview candidates for general surgery residency and the USMLE step 1 score is utilized as a marker for hard work and seriousness. We know that it doesn’t take a perfect score on the SAT or USMLE or MENSA status to be a great surgeon. Despite this, it is assumed that a high score on the USMLE relates with work ethic.

True or untrue? Whether or not you agree isn’t as important as the fact that the score matters so get the highest one you can.

“Oh, a low Step 1 score, this may be a resident we’ll have to worry about learning the material” or “Wow, 250, they must work really hard and be super smart.”

Are these assumptions true for a particular candidate? Of course not. If you’ve even made it to to the USMLE Step 1 you’re obviously an incredibly smart doctor. You have persevered through undergrad, did well on the MCAT, achieved the success of medical school admission and passed the gauntlet of the preclinical years. I personally don’t put much stake in the USMLE Step 1 but other people do and some programs may use it as a screen to be considered for an interview.

The USMLE Step 1 Puts You on the Playing Field with Your US Peers

One thing is clear, the USMLE Step 1 is the single number that puts you on the comparable playing field with your US grad peers. As an IMG a strong Step 1 score can turn the disadvantages associated with international education into an advantage. With a strong Step 1 score you’re now assumed to be smart and with an international education and experience you now are interesting, different, diverse, exceptional. A low step one score and an international education can lead application reviewers down the “oh, he couldn’t get into medical school in the states” pathway. Avoid this with a strong score.

What happens if you get a low USMLE Step 1 score? How do you recover as an International Medical Graduate?

Receiving that envelope, cracking it open to disappointment is a tough day for anyone. Now you probably open an email. A bad score is not lights out. This is when you’ll thank yourself for building your story early. For building a deep fan club of known people who can support your application. For having a few searchable items in Pubmed . A bad score is just one bullet point on your CV and if you have a lot of bullet points you’ll be fine.

Now that the USMLE Step 1 is Pass/Fail does that change anything?

Changing the USMLE to pass/fail is going to change a couple of things, for one it’s going to force review committees to take your complete application more seriously. You’re going to have to put a little more focus on your story and your fan club rather than just hit a 260 and think you’re set for the specialty of your dreams.

That’s where being an IMG helped me as it created this underdog mentality early in my education, I talked with mentors and started to build my story gradually, focusing it over the years. Keep reading for more on “the story” and I would definitely check out my “So you want to be a surgeon?” blog post to see how I put those early years together and what my life is a little like now.

Recommendation #3: As an International Medical Graduate Build Your Story Early

I’ve always said, whether it’s in general surgery or pediatric surgery or really any other specialty a successful match is really based on two things: Your Story and Your Fan Club. We’ll get to the Fan Club later on, but Your Story can begin early. This doesn’t apply to only the International Medical Graduate but also to US grads and everyone looking to build depth in their specialty of choice.

When I look at an applicant’s CV I want to see a progression of commitment to the specialty. It’s certainly ok and even encouraged to have experiences that jump from topic to topic early; however, as time marches on your story should become more focused.

Commitment to Surgery is Vital

My story towards surgery started with competing and receiving the Barker Prize in anatomical dissection at my medical school, the Royal College of Surgeons Ireland . But then I pivoted and applied and received a grant to study neurobiology as a research fellow during the summer between Year 1 and 2. I bounced around between specialties a bit, found great interest in Urology and then over to Neurology and Infectious Disease. Then I was on a geriatrics rotation and co-authored my first publication on subgaleal hematoma after clopidogrel usage and found satisfaction in adding experience to the medical literature.

In the midst of all of this I had found that general surgery was my path and general surgeons were my tribe. It’s funny because throughout medical school you’re going to be exposed to various specialties and the doctors within those specialties. In my experience there is a common trend that runs through all of the different docs, maybe a personality trait. When you find a theme that you mesh with you may have found your tribe, your specialty, your people.

Surgery was my path, Surgeons are my tribe

After finding my tribe I knew I had to make it clear on my resume. I had to take my interests and my wants and dreams and get them on paper for everyone to see.

One of my mentors would say…”Don’t tell me you want to be a surgeon, show me you want to be a surgeon.”

This advice has echoed in my mind through general surgery training, pediatric surgery fellowship and on to being an attending surgeon. I’ve passed it on to students and trainees over the years and I think it’s critical. Over the years in medical school, DO THINGS that SHOW your commitment to a particular specialty.

What rotations have you done? What papers have you published? Have you secured any research grants or presented at any conferences in your specialty? Have you done sub-internships in your specialty at your institution and others to develop your interests?

Be authentic

Recommendation #4: Find Mentorship, Build Your Fanclub

Part two of the successful match is building your FanClub. You’re going to want to develop relationships with the Chair of your specialty at YOUR program and the program director of your chosen specialty at YOUR program.

Make appointments with them as soon as you’ve decided on pursuing that specialty. In my opinion the earlier the better. And after you’ve established that relationship, build on it…and most importantly…don’t flake out. I repeat, don’t flake out. That time in bold.

If you say you’re going to do a project, do it. One sure fire way to end your future career in the specialty of your choice is if you flake out on your own program’s leadership.

I’m a huge fan of away rotations. They help broaden your experience. People say, what if you make a bad impression? If you’re genuine, humble, hard working, nice and yourself it doesn’t matter how much you know. Be curious, ask questions. You don’t need to be all knowing to be successful on an away, you just need to take it seriously.

I did aways as often as I could. I even took time off, a few weeks here and there from my own program to complete aways that overlapped with vacations. Any time I could do an away rotation I would do one. I did 4 all together…all in general surgery. By my last sub-I, I was on fire. At every away, write a paper and ask for a letter of recommendation.

Be Better than the People Around You. Whatever it takes.

There is a certain style and approach to asking for letters of recommendation. Make an appointment with the chair and program director early in the rotation and give them a packet for your letter. This packet would contain a cover letter about your experience, your curriculum vitae, and all the material they need to write the letter and upload it to ERAS. Be a professional. Be someone they would want to hire.

One piece of advice I think is incredible important for the international medical graduate is to get a supporting letter from a program director or surgery chair in the United States. If you are going to do a rotation in the US as a sub-internship do not do a subspecialty.

Rotate on the Program Director or the Surgery Chair’s Service

If you’re an international medical graduate applying to general surgery do a rotation in general surgery on the program directors service or the surgery chair’s service. Do anything you can to get on one of these two services.

When I rotated at Baystate Medical Center for my first Sub-I I made sure I was on Dr. Richard Wait’s service, the surgery chair. When I did my second Sub-I at Mayo Clinic I made sure I was on Dr. David Farley’s service, the program director. When I did my Sub-I at Northwestern I was on Dr. Nathaniel Soper’s service who was both the program director and the surgery chair. From each of these leaders I obtained a letter of support for my application and waved my right to see them.

Letters from US Program Directors or Surgery Chairs are Very Important

While I can not say this for sure, I do not believe the letters from your home program will be as strong as the letters from your sub-internships in the United States. Especially if these letters are from known surgeons, surgeons who write a lot of letters. And if your letter stands out from the vanilla letters that they write because you were on their service, then all the better.

These letters will serve as fan mail you’ll add to your application for The Match.

Your fan club is important, build it early.

Recommendation #5: Apply As Early As Possible, Don’t Delay

Remember that some programs start seeing applicants, considering and inviting them for interviews beginning the first day of the application cycle. Have your application into ERAS right away, at the earliest possible time. When I talk with applications and it’s later into the cycle and they don’t have their application in I think “lazy and unprepared.” Don’t have someone thing “lazy and unprepared” when it comes to your application.

Remember there are only a few interview spots compared to the number of applicants, maybe a few dozen interviewees for thousands of applications. As an international medical graduate, your goal is to get an interview. Then a new game starts.

The best chance, the best advice, even if you haven’t done any of the above is to have your application in on the first day.

Recommendation #6: International Medical Graduates Should Apply Broadly

I applied to 64 programs, a mix of community and academic programs. There were fellow IMGs who applied to larger number and some a smaller number, mixing in prelim and categorial positions. My approach was that I only applied to categorical and I thought that if I didn’t match I would scramble into a prelim spot as there are usually several open every year.

Maybe it was a poor strategy and things have changed over the years but it worked for me. With 64 programs I had a heap of rejections and landed 17 interviews and I went on most of those.

Apply to programs that are a reach for you, programs that are right at your belt level and also to programs that you perceive as less competitive. Maybe some of these programs will be community programs and maybe there will be a few prelim spots. This will be different for everyone.

Going on these interviews to all types of programs will help define what you want for your training

For some people Mass General may be the BEST training program for them, for others it’s a community program in a more rural region.

As an international medical graduate applying broadly will give you every opportunity, and you’re going to get a heap of rejections so be ready for them. I remember I got a rejection from Ohio almost immediately after submitting my application. Guessing the was the IMG screening computer. You’ll find this, but it’s just part of the experience, Be Teflon, don’t let it get the best of you. I had another program call and tell me to apply to their prelim program because they didn’t take IMGs for their categorical program. No thanks. It’s a journey, it’s an experience and there will be ups and downs.

What do you think? What is your experience? There is a lot of advice out there, check out this recent post from the AMA . Listen to all of the advice you get and bend it to your needs. Good luck!

Also, once you match, check out my post on how to be an awesome resident . I think this advice is applicable to all specialties. Would love to hear what you think! The body content of your post goes here. To edit this text, click on it and delete this default text and start typing your own or paste your own from a different source.

Becoming a Surgeon

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 13:37:29 GMT

"Every day, in simple interventions, more technically complex operations, in conversations with families or in meeting with my colleagues I get to serve, save lives and alleviate suffering."

I am a surgeon.

Every day, in simple interventions, more technically complex operations, in conversations with families or in meeting with my colleagues I get to serve, save lives and alleviate suffering.

Those of you who follow pediatric surgery icons may notice that this is taken from a quote by C. Everett Koop , a pediatric surgeon and former United States Surgeon General.

When asked to describe his decision to pursue a life in medicine Dr. C. Everett Koop responded:

“I have never regretted going into medicine. I’d do it again tomorrow, and I tell that to any youngster who is considering it. Medicine is a calling. It is more than a business. One can make money doing other things. But I chose medicine–surgery–because it combined a quest for knowledge with a way to serve, to save lives, and to alleviate suffering.”

I find great connection with these words. Surgery is the discipline of applying mechanical solutions to medical problems. I like working with my hands, I enjoy seeing immediate results.

Complicated problems are interesting to me and I thrive on efficiency. I like to identify and solve problems. I find great satisfaction and joy working with children and their parents. Teamwork is vital and I am a leader. Surgery is all of these things. Mostly, surgery is being a physician with a skill set to serve, save lives and alleviate suffering.

What does a day in my life as a pediatric surgeon look like?

There are many different settings to be a surgeon and there are many different specialties in surgery from trauma to ophthalmology. You can be in private practice, academics, hospital employed, government service and the uniformed service to name a few. Each of these settings has its own appeal and I encourage your to actively engage yourself with different settings to find which one resonates with you.

There are plenty of resources out there from the American College of Surgeons and the Royal College of Surgeons to give you the broad strokes.

As a pediatric surgeon in Las Vegas working in a small group and serving our community at different hospitals including Sunrise Children’s Hospital and Summerlin Hospital I can give you the private practice perspective for a pediatric surgeon working with many hospitals.

Let’s take yesterday.

I woke up at 0500 and started my morning ritual…check out my miracle morning blog post and read Hal Elrod , it will change your life.

SAVERS.

Learn it and live it.

Take advantage of your morning, it’s the time of day you can control

By 0500 I had popped down stairs and made a cup of Stumptown coffee. I spent 20 minutes reading and then grabbed my water, threw on my bike shorts, and headed up to the deck to jump on the Peloton.

For 30 minutes I crushed a power zone workout with Matt Wilpers looking out over the Las Vegas morning.

The blood was flowing and the heat had already started to build, for me and for the city.

After a good sweat, I grabbed a shower, visualized and affirmed my day, helped make the kids a quick breakfast of oatmeal, drew my three kids their pictures to color (Henry a Ninjago warrior, Charlotte a unicorn and Ellis some shapes). Talked with Lis about the day’s events and jumped into the car by 0640 to get to the hospital for 0730 cases.

Make sure to get some personal time in the morning, even if it’s a few minutes.

Using SAVERS will help you build this into a routine.

After a 25 minute drive listening to my audiobook, currently The Icarus Deception by Seth Godin , I arrived at the hospital, said my hellos and consented my fist patient for a gastrocuteanous fistula takedown and headed to the OR.

I always like to get to the hospital early, at least 15-20 minutes before the case to make sure everything is smooth and the OR is ready. Setting up the day makes such a difference in getting off to a smooth start. Not just for me but for everyone.

Between my first case and the second case, a Nissen fundoplication, gastrostomy tube and tracheostomy on a child with multiple medical problems I rounded on the floor seeing patients with a variety of conditions from post operative appendicitis to pancreatitis, swung through and visited my NICU patients and spoke with the neonatologists and pediatricians.

After the second case I finished lunch in the doctors lounge and then sat down on my laptop to complete my notes, answer emails and prepare for an afternoon interview for our ECMO program. I was not on call and so only had the two cases which is a light day. At 345 I met with the video crew and our interview panel and we filmed a video for the Surgical Playbook, a set of tools to help other hospitals build an ECMO program.

Being a surgeon is not just surgery, it’s being involved and engaged.

By 530 I made it to the car, back across town, another 30 minutes in the car where I caught up with some patient phone calls, more audiobook and then home. I took over for Lis with the kids and bath time, we read books and got little ones in bed by 0800 which included lying on my daughter Ellis’ floor until she was asleep. A cup of tea and time with Lis and off to dreamland.

How’s that? Not too bad right?

Some days are different with the content but the structure is usually the same. I wake up early, do my miracle morning, get my exercise in, see the family and head to the hospital. Most days I’ll be operating or assisting my partners with more difficult cases and if I’m not in the operating room I’ll be in clinic or rounding and doing quality improvement work. Usually the day ends around 430 or 5pm, some days are shorter and others longer.

Embrace a littler chaos, not everything can be planned

In my practice I spend 95% of my time between two hospitals and I have three others partners who are pediatric surgeons. We split the call equally each taking about 1 call a week and 1 full weekend a month, Friday morning thru Tuesday morning. Every day is a little different and we’ll usually have one full clinic day seeing new patients and patients who are post operative.

Most every day I get to spend time with my wife and three kids and I try not to have anything interfere with these early evenings. If I have more work to get done on the computer or with notes, it happens after everyone is asleep or before anyone wakes up.

This week I operated a little every day, a bunch of cases one day and a couple of additional cases each other day. A few meetings in the early AM as I’m on a few committees with the hospital.

How does my pie look?

In my previous blog posts I’ve talked about the size of your pie and how you define the pieces in it.

My pie is below and here are the pieces in it: clinical surgery, family, personal/fitness, administrative/research.

This is based on a Monday through Friday week, I’ll usually take one clinical call a week and one weekend (Friday thru Monday) a month.

So looking at Monday-Friday from waking to sleep (0500-2100) and 8 hours of sleep a night.

120 hours per week

Personal 10 hours

Clinical surgery 40 hours

Administrative 10 hours

Family 20 hours

Sleep 40 hours

The weekends are up for grabs, usually if I’m not on call it breaks down to personal time for a couple of hours in the morning on my bike, family time through the day and then we try to get in a date night or two.

In June of this year (2019) I completed my first Ironman and leading up to that, with unbelievable help from Lis, I spent most of my off weekends on the bike, out on the road or in the pool. Now things are a little, a lot more calm.

Some surgeons have very different “life pies.” They may have time for societies, more administrative time, more research or teaching. Some, especially in my community, have more clinical volume and spend their weekends doing elective cases which certainly affects their time.

If you were to add these slices in to your pie, which pieces are likely to get smaller?

I’ll give you the answer…sleep, personal, family and clinical surgery, maybe even in that order. If there was a piece that I would like to enlarge it would be research. As I get more efficient with my clinical work I’m finding that I can do the same amount of clinical work more efficiently and begin to ask some important questions in the surgical quality space.

The key I’ve found to finding that time without changing the pie is to be able to sit down and work on my laptop, anywhere.

Sometimes it’s the doctor’s lounge, sometimes it’s in the OR between cases, sometimes it’s in the office and sometimes I’ll find myself at Vesta coffee roasters working, enjoying coffee and waiting for the next consult to come in.

Is the profession of surgery getting more attractive or less attractive as a life?

I think it is getting more attractive, especially when compared to other medical disciplines. The toolset in surgery as a skilled operator, a trauma doctor, a leader and innovator simply can not be replaced by a computer, software, robots or an advanced practice provider.

As a surgeon I have tremendous satisfaction in my work and as a private practice surgeon I have control over my personal and professional life. I get to have an active role in quality improvement in my hospitals and quality and safety improvement in my community.

Pediatric surgery is an incredible career and at a time when many physicians would not recommend their career to their kids, I would love to inspire my children to a life in surgery.

Do you have what it takes to be a surgeon?

Are you curious?

Do you like to set goals and achieve them?

When the going gets tough do you step on the gas?

When the pressure mounts to you focus or do you fold?

To quote Seth Godin , are you an artist?

Do you enjoy solving difficult problems, especially with your head, your heart and your hands?

Do you have grit?

Are you a leader or would you like to become one?

Can you be critical of yourself?

Can you be critical of yourself in front of others?

Are you a team player?

If the answers to the above questions are “yes” more often than they are “no” I would say you definitely have what it takes.

What is the path to surgery?

It’s a long one. But remember, there is a difference between school and training.

When people ask how long does it take to be a surgeon they always have a blank stare or puzzled look when I answer. I’ll say “well, the choices you make after high school include 4 years in university, another 4 years in medical school, 5 years in clinical surgery training, 2 years in research, and 2 additional years of fellowship training, so about 17 years.” And that’s the quickest someone could do it for pediatric surgery; perhaps someone could do it in 15 or 16 years without any research but that would be unusual.

For me I took a year off between undergraduate and medical school and I spent an extra year in undergraduate so I was the ripe age of 38 when I started my career as a fully trained pediatric surgeon.

How could you go to school for that long?

Remember, for most of it you’re not in school, you’re in training. And when you’re a trainee you get a modest paycheck (was somewhere around 51k/y when I started), you get medical benefits, you even get a 401k at some places! The years in training go by quickly…and for the most part they are a lot of fun despite the long days and nights.

I’m going to put this in bold because it’s important, you should never decide on what type of doctor you want to be based on the length of training. Period. If you do you’re going to be in trouble. The things that change between being a trainee are control, income and responsibility. They are incredibly important but I would not sacrifice a few years in the short term to do exactly what I am passionate about.

Medicine is too stressful of a career to not spend your days doing things you’re passionate about.

Remember to spend your years in medical school being curious, go to every clinic you can, get into every operating room, which areas are you the most curious, where are you the most happy, which places in the hospital do you want to go back to?

The real path to surgery begins in medical school and as I was a foreign medical graduate at the Royal College of Surgeons Ireland it started early in medical school. First, you’ve got to get into medical school but once you do and you finish that first white coat ceremony, you’re in! Now time to mush on.

It’s good to be interested in everything. But when you’re ready to choose, focus.

If you ask me when I knew I wanted to be a surgeon my mind will certainly go back to the early days in the anatomy lab where I spent 18 months with retired surgeons and anatomists learning the intricacies of the human body. I thrived in the anatomy course and many days dissecting my cadaver I visualized myself with a sick, live human. My dedication in the lab would give me better insight when I needed it most in the years to come.

Those days were the beginning and they were awesome. I remember vividly competing with my mate Dr. Gary Bass in an anatomical dissection competition over the course of the year. We both did the head and neck, I did the facial nerve and Gary did the zones of the neck. Those days spending hours over our cadavers were the foundation of where we’re both at today.

My time in the anatomy lab was the spark. It was a special time. It was a privilege.

The real decision point came when I did an early sub internship during my third year of medical school at Baystate Medical Center. There was a chief resident, Dr. Alex Perez, on the general surgery service and I wanted to be just like him. A trusted leader in and out of the operating room. He is a teacher and learner, his clinical expertise on the ward, in the trauma bay, the ICU and in the operating room was inspirational. I made mistakes and he would let me know.

Forgive and Remember.

While I worked hard during this rotation, living in the hospital on a cot for the month, I loved every moment of it. It could have been miserable during that dark winter in Springfield but it was the mentorship and example of Dr. Perez that made me know that surgery was exactly what I wanted in a career.

For all of us, the decision to pursue surgery most likely comes down to a few very inspirational mentors.

If you’re a surgeon and you’re reading this, can you remember the first mentor that really inspired you? If you’re a student and you’re reading this, how can you surround yourself with the mentors to inspire you? What are you doing to put yourself in contact with these mentors?

I’ve decided I want to be a surgeon, now what?

After the decision to become a surgeon the real work starts: building your story and building your fan club. As a surgeon who interviews candidates for surgery residency I look at the story and the fan club. So let’s take these separate:

THE STORY

The story of a successful surgical applicant is a series of decisions that demonstrate authenticity and a genuine interest in surgery. Strong applicants have a history of decisions in their medical education that build a skillset for surgery.

They have done well on their surgery rotations where their commitment, curiosity and interest was noted above their peers. They’ve asked questions and pursued research, case reviews or quality improvement projects at a very basic level. Successful residents have followed these through to publication or implementation.

Sub internships in surgery and experiences in radiology or critical care were completed to broaden their education and skill set.

Successful candidates have painted a picture of someone who wants to serve, save lives and alleviate suffering.

Notice: I did not say that this person crushed their USMLEs…but this is a topic for another blog post.

THE FAN CLUB

As you are creating your story you’re building your fan club, the two happen at the same time. That great mentor you met on your surgery rotation, that’s a fan.

The professor you published your research paper with or the surgeon you did that QI project with – they are both fans. These fans will write your letters, make phone calls on your behalf and stand up for you when you need help.

As your fan club grows keep in touch with them, send them emails or phone calls and let them know about your successes. When years pass and you’re still looking for a letter writer, someone who may be able to pick up the phone for you or a job they will be there for you.

I’ve mentored students who made the decision late in the game, and this is absolutely ok.

The point is, when you make the decision to pursue a specialty, you dive in. Whether it’s early or late it’s important to be authentic.

Don’t be a flake.

What are some of the decisions you can make right now to pursue a path in surgery?

1.) Get to know some surgeons and spend some time with surgery. If you’re a medical student this is easy, find a surgeon and see if they’ll let you tag along during the early years. When I was in the preclinical years I hooked up with the urologists who also did the renal transplants. After I finished my studies I would go and hang out in clinic, do cystoscopes, go to the OR, go to transplants, it was a blast. AND it definitely helped answer the question early on if I wanted to be a surgeon or not.

2.) Get some leadership experience. You can accomplish this is your community, at your school, in your sports and in your societies. Find your local ACS chapter and see what options they have for medical students. What charities can you hook up with that align with your interests and passions. Go do some coaching or lead a sports team to victory. There are so many options for you and gaining leadership experience, now just go do it.

When we’re in discussions about The Match whether it’s fellowship or residency or even your first job the question comes: Is this person a leader?

3.) Go to a surgery meeting like the American College of Surgeons Annual Conference. The ACS Annual Conference and you’re not inspired then this may not be the profession for you. The ACS conference is a huge collection of students, residents and surgeons from across the globe and it is awesome. You get to learn just about everything about surgery. You get to connect, network, meet like minded students and residents. It gets you pretty pumped, if I could I’d go every year.

4.) Get some research going and get something published. Another thing that can help build your story, and build your fan club and help you decide on a career in surgery is to start a small research project. Maybe this is just a chart review, maybe this is a proper quality project or a case series. Whatever it is it will allow you to read relevant literature and work with a mentor to add something to the surgical knowledge sphere. My first paper as a student on subgaleal hemorrhage didn’t change the world, but it struck a cord with me. I found it an opportunity to serve my community, add something original and I liked it.

These are experiences, this is my story. Yours will be different.

In summary, I hope I provided a few examples and m aybe a little glimpse into living as a surgeon and getting here. If you want it you can do it. If you don’t, that’s completely good as well. The important thing is to find something you love and pursue it passionately.

Burnout: The Greatest Threat to Medicine

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 13:35:22 GMT

"You see it in the news, you see it on twitter, see it in your colleagues, hear it at the water cooler, maybe even feel it creeping up on you."

Burnout is the Greatest Threat to the Practice of Medicine

Burnout. It’s all around us.

You see it in the n ews, you see it on twitter, see it in your colleagues, hear it at the water cooler, maybe even feel it creeping up on you.

I’ve been reflecting a lot on the concept of burnout given these obnservations. I’m a pediatric surgeon and am (as of this writing) 5 years or so in practice after nearly 10 years of post graduate surgical training. Add on medical school, undergraduate education, and research and you have most of a lifetime.

I’m not burnt…not yet

I’m early in my career but just because you’re early in your career or if you’re a resident or a medical student it does not mean that you’re immune from burnout. For me I feel shielded because I chased down the surgical subspecialty that I was most excited about and fortunately pediatric surgery has been an excellent match to both my skillset and my mindset. I’m convinced that going after the specialty you want most and understanding the why is very protective when it comes to burnout.

In pediatric surgery I get the opportunity to alleviate suffering and save lives.

I love taking care of children and their families. I cherish my responsibility whether it is removing a rotten appendix or curing cancer, from helping the adolescent with pilonidal disease to closing a newborn gastroschisis, from seeing lumps and bumps in clinic to visiting with expecting mothers in prenatal consultations.

Pediatric surgery is a job that in the one hand can be extremely stressful, even terrifying, in the other I get to experience the joy of curing disease and returning a child to their parents anxious arms.

For me, I couldn’t imagine a more satisfying career path.

While you may not be experiencing burnout, it’s still important to be in tune with triggers of burnout and to know if you or your colleagues are on that slope. Chances are you worked with someone today who is struggling from burnout, they have all the signs and symptoms but don’t know what to do about it.

Burnout and the numbers…

You may have already read this article published in the Harvard Gazette Study: Doctor burnout costs health care system $4.6 billion a year and the most recent statement on physician burnout. Specifically that it’s been a problem, it still is a problem, it’s getting worse and it’s costing billions.

$4.6 Billion

a conservative estimate of the financial effect of burnout from reduced hours and physician turnout, not counting the downstream effects including medical errors, patient dissatisfaction, malpractice and stress.

54 Percent

of doctors reporting at least one of 3 symptoms of burnout: emotional exhaustion, cynicism and detachment, and a sense of low personal accomplishment. Double the normal population.

Crazy right? Think about that…one in two docs are suffering from burnout. I was in the doctors lounge today with at least 30 docs, surgeons and physicians…that’s a whole lot of burnt out people.

Another article from Sharona Hoffman summarized the problem quite nicely and made the bold statement that medicine may no longer be the best vocation for talented students to pursue.

When we think about physician burnout a lot of the following words and responsibilities come crashing in:

Electronic health record

Documentation, record keeping and data entry

Insurance hassles – prior authorization, denials and appeals

Decreased reimbursement

Increasing demands for productivity

More patients in less time

Inflexible schedules

Limited time for personal health and family

Regulation

Sharona also points out what burnout leads to for doctors and their patients: depression and medical errors. It’s incredibly striking.

One of the reasons I wanted to write this post is to learn more about burnout, find out why I don’t feel like I’m experiencing andsee what I can do to help my colleagues. I wanted to find out what the triggers of burnout are because it’s obvious that it’s not just one thing.

Burnout is definitely a complex problem but are there some anti-burnout habits we can identify to help us?

It’s my firm belief that medicine, any specialty, is stressful and it’s going to get more stressful as we move forward with the increasing complexity our healthcare system. Within this complex web, I’m going to tell you what I think is the slippery slope of physician burnout.

The NUMBER ONE reason for burnout in medicine and surgery: Losing Boundaries

If physicians and surgeons could have a typical day that focused on patient care, I don’t think we would be talking so much about burnout. But we are. Unfortunately, while a doctor’s day may have patient care in it but many times the day is full of a crazy swarm of other responsibilities.

Committee meetings, medical documentation, quality projects, small business decisions, discussions with insurance companies (especially their frustratingly impossible phone trees), administration, teaching, research, phone calls and emails.

Physicians and surgeons are selfless when it comes to patient care; they are also selfless when it comes to these non-patient centered responsibilities. It’s my opinion that the shift in medicine away from patients and toward these “other” responsibilities has lead physicians exponentially toward burnout.

What non-patient centered responsibilities filled your day today?

What could you have wiped off of the calendar?

What meeting could have been handled by a conference call while you were on a walk or run?

As you start thinking about burnout I also want to refer you to a thoughtful post by the American Medical Association and you can check it out at the AMA website .

1.) Do you have a high tolerance of stress?

If the answer to this question is yes, you’re risk of burnout is 15 times higher than if you answered no. This is according to Dr. Mark Linzer, a general practitioner with an interest and expertise in burnout.

You may think that you are uniquely fit to accept high risk.

You’re not.

You are as susceptible as anyone else to stress.

What makes me stressed?

Do I have an unpredictable schedule?

Do I feel in control?

What am I lacking?

Does time go fast or slow?

When is the last time I laughed with my children?

When is the last time I laughed with my partner?

Write the answers to these questions down.

Talk to your family, have them answer these questions too.

Does your wife or your husband feel like you have a predictable schedule?

Does your partner feel like you’re more or less stressed?

When does your spouse say you planned the last date night?

Knowing the answers will give you perspective on where you are at with your job and where you are at with your family. If you’re a resident check out my post on how to be a stellar resident, this may also give you a few tools to reduce stress in your life.

2.) Would you describe your practice as organized or chaotic? Is anyone in your practice experiencing burnout?

When you’re in medical school you probably thought that your patients would be the biggest source of daily stress.

Am I going to be able to do that operation?

Or will I be able to make diagnosis?

Surgery becomes the easy part, your patients are your solace, your safety net.

Walking the halls of the hospital is the practice that calms you.

So if the patient care becomes the easy part, what are the stresses of clinical practice?

Here are some questions...

How do you reduce the chaos in your practice?

What are the weak points that cause stress?

How does your scheduling work?

What about referrals?

Do you have a smooth EMR or a lack of EMR?

Do you have stable office and clinical staff?

How do you relate with your partners?

These questions will help you identify the daily struggles in your practice, whether it’s hospital employed, academic or private practice.

3.) Do you agree with the values of your leadership?

When you don’t agree with the values of your leadership, whether it’s in a hospital system or in a private practice, your stress level goes up and I imagine that emotional exhaustion accompanies this in short time. Agree?

If you had to write down YOUR mission statement on a piece of paper what would it be?

Write down your values on a piece of paper. What are they?

Do these align with the mission statement of your employer or your group? What is their mission statement? If they don’t have one, what WOULD it be? How about their values? How can you align your values these mission statements?

If you can’t align your mission statement with your employer’s or you feel that your values are maligned you have two choices:

1.) Find a resolution with your team

2.) Find a new team

4.) Does your job interfere with family events?

In training we’re taught that we’re going to have to miss birthdays and anniversaries, we’re going to have to put everything before our personal time and our family.

Disappointing your family leads to stress, emotional exhaustion, detachment and yes…burnout.

I strongly believe that repeatedly telling your children you’re not going to make that performance or that soccer match or that recital or school event not only disappoints your child but disappoints you as well. That disappointment builds up over time.

How much control do you have over your job? What are the things that are keeping you from control? For example, is it predictability? Do you know when your cases will go on? Do you know when your clinic is scheduled? How long ahead is the call schedule made? Can you plan vacations and weekends away with your family?

Here’s some advice: If you are stressed clinically, start saying “No” to additional responsibilities, start saying “No” to the other stuff

You don’t need to be on that committee. You don’t have to be in that society. That quality project can be led by someone else. You can say no to that teaching post. Research can wait.

If you’re not stressed clinically, and you have a clinical job, then of course, say “yes” until you start to feel stressed. The trick is, don’t say yes to everything at once

One of my mentors shared a story that I’ve shared a time or two. When you’re defining your career, you can’t choose the size of the pie but you get to choose how many pieces are in it. And the first piece to get smaller is your family. Remember, you can’t have control over your schedule until you learn to say “No”!

5.) How would you describe your physical and emotional health?

Do you workout daily? Weekly? Monthly…ever? When was the last time you booked a massage for yourself? When was the last time you scheduled clinic an hour later so you could enjoy that morning run? What’s getting in your way?

It’s obvious to me that failing to care for yourself is a surefire path to poor health, lack of motivation and burnout

Are you having burnout or are you just tired?

How are you feeling about burnout now?

Hopefully you have given some thought to your level of burnout. You’ve thought about the pieces of your professional and personal pie, which pieces take most of your time and which pieces may not need to be there. You’ve thought about your job and your employers, you’ve drafted a mission statement as well as your core values. Hopefully you’ve identified some items you may be able to get out of your calendar and out of your day to day responsibilities.

It can be hard to decide whether you’re just suffering from fatigue or if you’re suffering from burnout . So which one is it?

One easy way to look at this is your ability to bounce back.

Are you tired every day or was it just a long week?

When Monday comes are you dreading coming to work every Monday or just this one?

When a call is approaching, how do you feel?

An objective measure of burnout is known as the Maslack Burnout Inventory is an introspective evaluation of 22 different items pertaining to occupational burnout. It focuses on three particular areas:

Emotional exhaustion = “I’m tired all of the time…”

Depersonalization = “It’s the patient’s fault…”

Personal Accomplishment = “What’s the use? It doesn’t matter…”

When you find yourself struggling with any of the above you may be on the slippery slope toward burnout. And that’s just it…Emotional exhaustion begets de-personalization which leads to decreased feelings of accomplishment.

We’ve spent a lot of this discussion Identifying the problem areas of your life…that may be your hospital, practice, administrative duties, and health among others.

What are some quick wins?

What behaviors help avoid and prevent burnout?

Strategies to avoid burnout

1.) Find your passion…today

What is it you love about your job? Why did you become a pediatric surgeon, a trauma surgeon a breast surgeon or an orthopedist?

I keep a bulletin board full of cards from patients, drawings, some photos patients have sent me. This board sits right in front my desk and I see it every day. I’m reminded of tough patients and challenging cases.

I laugh at the crayon drawings by a 5 year old who drew her interpretation of us in the preop area, she even included my Vegas Golden Knights scrub cap. These drawings and photos are right next to the photos of my children, wife and family, they keep me centered, present and they are a constant reminder of why I do what I do and why I love it.

Do you have a podcast you like to listen to? What do you reference that gets you pumped up?

2.) Book time for your health, Book time for your hobbies

When I finished pediatric surgery fellowship I was excited to take on the world but the years behind me had taken their toll. I was chronically fatigued from the intensity of fellowship, I had gained a fair amount of weight between snacking in the OR, morning chicken biscuits and fried food Friday, many nights falling asleep with potato chips in hand. I hadn’t run a mile in two years. If I didn’t do something I knew the burden of life would spin my health further into a dark hole. So what did I do?

I signed up for a half Ironman

When it comes to making time for your health, often it comes at the end of the ticket. It comes after the days work, after the kids go to bed, after the notes are written for the day, after time with your spouse, after the dinner is made, always after...

I found it very difficult to fit in daily exercise and fitness until I signed myself up for something that would hold me accountable for exercise, for me, at that time, unable to run a mile, the half ironman would be just what I needed to get on track. It seemed borderline impossible but entirely achievable. So I made two goals:

Half Ironman by 39

Full Ironman by 40

My wife Lissy was extremely supportive and I put my workouts in the calendar for every day. I treated these appointments as important as anything else and since they were everyday at 430 or 5 in the morning for an hour, sometimes two, they were easy to fit in the schedule and not miss time with my family or work. When I got burned out or I thought I couldn’t do it I would turn on Youtube and watch inspiring videos of athletes completing the Ironman in far weaker health with far less resources than I have.

The morning is the only time of day I can completely control

Within a year I lost all of my extra weight, I felt boundless energy, and accomplishment when I crossed the finish line at the Santa Rosa 70.3 in 2018. A year later I found similar elation crossing the finish line at Ironman Boulder 140.6 hearing the famous words:

“You are an Ironman”

You don’t need to sign up for an Ironman, I had to in order to hold myself accountable for improving my health. If you’re having problems fitting your time for health in I recommend the following:

Account for yourself, put it in your calendar, every day
Schedule the amount of time and exactly what you’re going to do
Review your health accomplishments at the end of every week
Identify reasons why you missed workouts
Challenge yourself with something that is beyond your abilities, something you will have to train for to finish it.If you still can’t complete the workouts

If Ironman isn’t your bag and you need something besides a focus on health answer this question: what hobbies do you enjoy? When was the last time you engaged in a new skill or interest? Write down a list of things you’ve wanted to learn.

For me I am interested in the culinary arts and the list begins with things like: brewing beer, developing salami and cured meats, building a cheese cave, container gardening and evolves into other interests like classic American literature, poetry, writing and theater. I keep these lists with me in notebooks and refer to them often…there is so much to learn, what should I learn now?

3.) Think about your values, write down your mission statement

During this post I hope you’ve had the opportunity to reflect on why you went into medicine or surgery. That you’ve had the chance to reflect on what you are passionate about, what about surgery gets you up in the morning. Your values are rooted in that passion. Your mission statement is these values distilled into a single phrase.

If your values and mission statement are not aligned with your daily work, burnout is inevitable

As we discussed before regarding your work and your leadership. Do you feel valued in your job? Do you agree with the direction of your leadership? Are you a decision maker? Are your values and mission statement aligned with your leadership? Does your leadership have a mission statement?

Answer these questions and then find out how you can align your values and mission statement with your group or your hospital. If you can’t, then it may be smart to start rethinking where you work.

4.) Family

When was the last time you laughed? When was the last time you felt absolute joy? I can tell you for me it was the last time I read my kids their bedtime stories, it was when my 2 year old Ellis came down the stairs before breakfast and said “jump with daddy” (code for “let’s go jump on the trampoline”), when we play hide and seek at night, when my wife and I sneak away for a run, a walk, dinner or an adventure with friends.

People say that at the end of your days you’re going to want to have spent more time with your family, with your partner and your kids

What will it take for you to accomplish this? Say no to being on that committee that meets in the evenings. No to that extra teaching session. Say no to that invited talk. The clinical stuff is more difficult to say no to, but the non clinical stuff, that’s ripe for opportunity.

And when you find this time, schedule time in your calendar with you family. Make this time as important as everything else. Plan that date night on an evening you’re not on call. Take a weekend away. Plan a family hike. Plan, plan, plan and plan some more.

5.) Seek mentorship

Reading this you may be at any stage in your career. If you’re a medical student or a surgery resident it’s likely you have a mentor. If you don’t, then I highly recommend you find one. Mentors are probably life’s most undervalued resource. Many of us ascended through education and training to our current position because of our mentors.

Mentors do more than review personal statements and suggest or write letters of recommendation.

Mentors are a life guide, they provide education and guidance, give feedback, influence and help straighten out paths that seem impossible or hard to reach.

Why do mentors have influence on burnout? It’s my opinion that part of accelerated burnout is losing your way, losing your reasons, your why’s, getting distant from your passions and submitting to the grind. Mentors can act as a check and balance during the evolution of your career.

Who else holds you accountable besides your self? Usually your partner will hold accountable but this isn’t always reliable. Emotions are involved. Mentors can influence and guide you from outside of your lens.

6.) Say “No” = Control Your Calendar

During my residency I was fortunate to be on a leadership team where an invited guest from the business or healthcare community discussed topics of interest from giving feedback to leadership. During one of our monthly meetings our guest discussed the concept of “No”.

I’ve referred to it above, but one concept I took away from the discussion and passed down to colleagues and students is this: until you learn to say “no”, you will never be in charge of your calendar. In residency, we’re in the “yes” community, we say “yes”. What other word is there?

Yes works to a point.

You say yes in the beginning and you take on a project.

That project is finished and then more projects come. You say yes to those projects, some you finish and some you don’t and then more projects come. To those projects you finish even fewer, maybe none, and now you’re over your head in projects and their towers get taller as you fade into this “yes” saying entity that accomplishes nothing. Too much?

As I’ve written previously, and I refer to again and again, you don’t get to choose the slice of your pie, but you do get to decide how many pieces are in it!

Go ahead and get over to the resources section or check out my blog posts on finding that dream job. You’ll find a worksheet to help you draw your pie? Wha

Rural Doctors are Heroes

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 13:30:55 GMT

"Despite the interventions, he felt he no longer had the resources to care for this child."

The other day while on call I received a message from the transfer center that a doctor wanted to discuss a sick child he felt needed to be transported to a higher level of care. I answered the call and talked with the physician who was worried about this little girl.

A 2 year old had presented to his hospital with vomiting and loose stools, low grade fever and over the course of 24 hours she worsened with abdominal distension, tachycardia and agitation, on her way to shock.

An abdominal film demonstrated dilated loops of small bowel and a nasogastric tube decompressed her stomach.

Antibiotics were started for sepsis and she was fluid resuscitated. Despite the interventions, he felt he no longer had the resources to care for this child.

What is rural medicine?

Rural physicians represent 9% of the practicing doctors in the United States despite rural locales being home to nearly 20% of Americans. These physicians work in an environment with limited resources and in my experience have incredibly wide skill sets, deep medical knowledge, expert medical decision making allowing patients to avoid advanced imaging, and sharp acuity at deciding between the gravely sick to be transferred and those who will recover locally.

While there is a tremendous need for rural physicians, few medical students and residents pursue this career path.

There has been much written about a rural medicine pathway as a very rewarding career offering the opportunity to work in areas of true need, decreased physician burnout , an immersive patient experience where a physician may find themselves buying milk next to their patient at the local grocer (this also happens to be true in Las Vegas), and a greatly expanded skill set.

Why heroes?

I write that these doctors are heroes and should justify, as many would consider the super sub specialist who conquers new peaks in medicine and surgery on a weekly basis in urban megacenters around the world heroes.

These are the physicians and surgeons who are celebrated on our news channels, in our published peer reviewed articles and other media.

As a specialist, specialist defined as a career pathway requiring additional fellowship training, I work in different environments but in most I have unlimited resources including PICU and NICU intensivists, ECMO, pediatric anesthesiologist, an experienced nursing staff, a blood bank and many super subspecialists that are available to consult.

What if I didn’t have all of these things?

If I didn’t have those resources I wouldn’t be able to care for the babies and children I care for every day. I would not be able to confidently tell parents that my system is capable of caring for their soon-to-be son with a prenatal diagnosis of congenital diaphragmatic hernia. I would not be able to operate on the extremely premature neonate with necrotizing enterocolitis.

I would not be able to provide the multidisciplinary care required for severe traumatic injury. I would be able to care for and operate on the sick child but many things would be beyond my abilities and my system’s abilities.

Back to our patient

When this 2 year old was transferred I was present to evaluate her in our pediatric intensive care unit. She was lethargic and her abdomen had involuntary guarding in the right lower quadrant and right flank.

An ultrasound demonstrated free fluid in that area and concern for perforated appendicitis.

In the operating room I was able to remove the perforated appendix, clear her peritoneal cavity of purulent debris and achieve source control of her sepsis.

After the operation I called the referring physician and thanked him for sending the child, sharing with him the diagnosis. Within a day her complexion brightened, her abdomen softened and I found her in the pediatric floor playroom busy with unlimited stimulation.

Rural physicians don’t have all of the resources and tools I have at a tertiary center but they provide outstanding care despite these shortcomings, in fact I don’t believe they see the lack of resources as shortcomings at all, just a matter of fact.

The decisions these physicians must make are based not only on their expertise but on their knowledge of their healthcare system and what it can and can not care for with sick patients.

These decisions are the difference between life and death.

Take the patient with a history of angina and a physician without a Cath lab or access to cardiac specialists.

When do they send the patient for further testing or perhaps emergent bypass surgery?

If we define heroes as people who have courage, outstanding achievement and noble qualities the rural physician is a hero.

Questions

If you’re a resident or medical student have you considered rural medicine?

Why?

Why not?

Private Practice: The Antidote to Burnout?

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 13:26:59 GMT

"...Burnout as 'The Force' from Star Wars though I feel it’s closer to 'The Nothing' in The Neverending Story"

Burnout is the slow death in medicine and a new word in our lexicon this past decade. Some would argue this is not the correct word, that we should be using moral injury instead.

As a medical student in the early 2000s I never considered burnout, naively convinced that the emotional armor constructed over years of education and training combined with the secondary gain of caring for patients would protect me from this syndrome of exhaustion, depersonalization and lack of efficiency.

I was naive at best.

Dr. Dike Drummond in his 2015 article in AAFP and through his blog at thehappymd.com defines and describes burnout. He paints a bleak picture of the present and future in medicine, giving us the analogy of burnout as “The Force” from Star Wars though I feel it’s closer to “The Nothing” in The Neverending Story, a powerful and stormy antagonist destroying Fantastica one city at a time as adults increasingly lose touch with the fantasy of childhood.

Swap out “adults” for “doctors” and “fantasy” with “autonomy” and you get a clear picture.

In this post I don’t intend to go deep into the causes of burnout, the symptoms of burnout, how to prevent or treat it. Dr. Drummond has done that for us and I’ve made a strong attempt in a blog post on burnout I wrote a few years ago as a new attending pediatric surgeon.

My intention here is to describe how I feel as a private practice pediatric surgeon and my belief that private practice, a business structure that is rapidly vanishing across the United States due to vertical integration of medicine, helps prevent burnout by preserving autonomy.

Autonomy, I believe, is a key player in burnout, without it, it’s easy to become disillusioned in a very demanding profession.

Let’s define autonomy.

Autonomy is self government, the ability to make decisions.

In medical school we learn about patient autonomy as one of the four pillars of medical ethics . In life we value autonomy as a human by being free to make decisions. The greater our personal freedom, our ability to choose, the greater our life satisfaction. This isn’t just me pontificating, there is evidence in the sociology literature that perceived autonomy is positively correlated with a “good life.”

Conversely there is good evidence that work-stress and constrained autonomy are negatively correlated with health and life satisfaction.

The British Whitehall study examined British civil servants and identified that those with low autonomy and constrained freedom of choice had a much higher incidence of cardiac disease, though it easily could be argued that it wasn’t just constrained perceived autonomy that made the difference in health between the lowest and highest classes of society. Nonetheless, I find it interesting.

This begs the question, how is physician autonomy changing in medicine?

As a high school student I remember realizing the days of carelessness would soon be over and a life direction should materialize, protected and delayed a small bit by the years of college ahead. My life direction, fueled by my Dad’s employment as the manager in the radiology department at Capital Medical Center in Olympia, WA, turned toward medicine. To satisfy my curiosity I read books.

The first book that I found at the Half Price Bookstore in downtown Olympia was a worn copy of The Making of a Surgeon, by William Nolan . In this memoir of a surgeon reliving his schooling, internship and residency days we get an understanding of medicine in 1960s America. We learn the bias of the surgeon versus the medical men. We learn the hardships of training. We also learn the autonomy of being a surgeon.

After finishing this book I found another sitting close to it in the same section, The Puzzle People by Thomas Starzl , a memoir of a life spent chasing the dream of allogeneic transplantation and a fascinating story of the evolution of immunosuppression and surgical technical harrowism. I found the lessons in leadership and personal discovery fascinating, the physicians and surgeons led their respective institutions.

More books followed that continued to satisfy my increasing appetite for medical literature whether it was looking back to William Carlos Williams and Bernard Shaw’s “The Doctor’s Dilemma” or forward with books like Complications or the rules learned in Samuel Shem’s misogenistic yet thoroughly entertaining novel The House of God .

What I enjoyed about these books forward looking as a future doctor were the stories, hardships, struggle, intimacy and evolution from student to master in medicine, whether that be with a scalpel or a pen.

Ne’er did I encounter the modern hardships of working within vertically structured healthcare systems that shout “value care” yet seem to be distracted by producing the greatest returns for their shareholders and executives.

This will not be a rant on the discrepancy between what healthcare corporations say and what they do, rather, it’s worth pointing out the hypocrisy. And for the physicians and surgeons that work for and under the umbrella of this hypocrisy, I find that to be tremendously stressful. Here is where the beauty of private practice presents opportunity.

The Beauty of Private Practice

In private practice the partners answer to each other and while we are at the mercy of insurance reimbursement, hospital contracts, changes in political winds, hospital program development and other effects, at the end of the day the partners in the practice get to make a choice without the consequence of losing employment.

The ability to have that choice is very powerful. I’ve talked with colleagues of mine who work for larger hospital systems and if they want to continue employment, if they want to continue to live in that city, if they want to continue the status quo they must comply. I understand these are all choices too but the consequence is unemployment, not just reduced revenue.

“We want you to cover this new clinic 20 miles away.”

“We want you to increase your RVUs.”

“We want you to use this new EMR.”

“We want you to cover this new service.”

“We want you to be in house for trauma coverage.”

Response is okay, okay and okay. When I see a large hospital organization handing out free meal cards or bringing in a massage table or encouraging mindfulness as solutions to burnout I feel that they have lost the plot.

As a private practice surgeon my financial security is much less favorable than my employed colleagues whether they work for hospitals or for academic institutions. There is no salary. Reimbursement across the country is decreasing rapidly year over year whether that is from the privately insured or government insurance. Insurance companies are increasing the number of obstacles and hurdles it takes to collect. Hospitals are more and more reluctant to extend contracts for call coverage. Despite the difficulty on the financial front the autonomy that comes with owning and operating a small business is satisfying on so many different levels I struggled to appreciate them all.

Running a small business allows unlimited transparency and decision making. We see everything that comes in and everything goes out.

We can see if we’ve over hired our staff, we know if we have too many brick and mortar clinics, we get to choose the people we work with in our clinic and we get to choose the level of involvement in our hospitals. We feel a strong connection with our local hospitals and are deeply involved in program development to make the community a safer place for kids. This though is a choice, not a requirement and we enjoy this program development completely. As we discussed earlier it’s about autonomy, it’s about choice making, it has less to do with the money.

In a recent survey of pediatric surgeons only 7% are practicing in private practice, so I’m becoming a dinosaur, on my way to extinction…or maybe I’m not. The reason for my extinction is the vertical integration of medicine. Vertical integration is the merging of independent physicians, medical practices, physician groups and hospitals to create an organized healthcare network. This has led to an explosion of administrators to manage these healthcare networks.

Between 1970 and 2010 while the population of physicians expanded 150%, the number of administrators increased 3200% . It feels as though momentum is carrying us toward this organized healthcare network destination but there are costs. The major cost is physicians and surgeons transitioning from owners and operators to employees and giving up a significant amount of freedom. As employees in these systems doctors have also been demoted to “providers” alongside their nurse practitioner and physician assistant colleagues.

As a private practice surgeon looking at vertical integration from the outside I can feel the pull yet I want to promote the model of private practice to all who will listen and especially to those who won’t. As private practice surgeons we provide excellent care to the children and families of our community. We participate in leadership in local and national societies and in our hospital at all levels to improve quality and safety. We employ people who are a part of our team and we share in our successes together as we run a small business. We have freedom of choice and for that I feel protected from “The Nothing” that is physician burnout. I believe private practice is the antidote.

What are your thoughts on physician models and burnout?

Do you feel that the model of work or employment has anything to do with burnout or is it the stress of medicine itself that is “The Nothing”?

How to Crush Surgery Training - 10 Habits

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 01:19:29 GMT

"Anyone who tells you differently is either too far out from their training to remember or wasn’t paying attention."

What are the most important habits that successful surgical residents have?

Over the years I’ve worked with a lot of residents.

As a medical student, a resident and now as an attending pediatric surgeon I’ve looked up to them, been one of them and now teach them.

I’ve seen the success stories. I’ve learned from residents who have struggled, lessons that have given me guidance in both my personal and clinical lives.

In this post my goal is to provide the top 10 most important habits and strategies for the general surgery resident to crush their surgery training. These lessons can be applied broadly across specialties though I think they are particularly applicable to general surgery.

Do you want to do more than survive?

What if you could not only survive but finish with a depth of experience and limited wounds to show?

Because there will be wounds.

You will be injured.

Anyone who tells you differently is either too far out from their training to remember or wasn’t paying attention.

The ultimate goal is to learn the surgeon’s skillset while maintaining your physical, emotional and mental health.

It’s not necessary to be healthy, happy and balanced during your surgical education and training.

Surprising?

It’s your responsibility during 80 hours a week for 5 clinical years to learn an incredible amount of material so you can have clinical judgement while also gaining a technical skillset that will allow you to provide mechanical solutions to complex medical problems.

The strategies and habits that follow are lessons that I have learned and continue to learn over the years.

If you incorporate these habits into your training you will definitely see a positive outcome.

More importantly, these habits will help you learn the material, gain the technical skills and thrive while having the best possible outcomes in your mental, physical and emotional health.

Some of these strategies are obvious, some others are not. You get to decide what you want to incorporate into your overall educational strategy.

1.) Seek Mentorship

Seeking mentorship is NUMBER ONE on the list of success generating strategies and habits. Mentorship could be number one, two, three…you get the point. Whether your program actively engages you with a senior resident or faculty member or not, you MUST make a point to identify a senior resident and a faculty member who can serve as your mentor. Ideally this is someone you can connect with over the years.

The mentor-mentee relationship will last through the years that follow training. I still talk with and reach out to my mentors when I find myself in a difficult spot, clinically or personally.

It can confidently be said that most successful surgeons have had a relationship with an older, more experienced surgeon. Faculty with mentors are more likely to have career satisfaction, be successful in obtaining grant funding in research and receive clinical experience and wisdom that only accrues with clinical experience.

Mentorship with Residents

Mentorship with a senior resident provides you with a path that’s “close to home” to get through residency with a smile on your face. Senior residents have had their down days and have developed the resilience to get through those troughs. These lessons are incredibly helpful for a junior resident as difficult days and rough patches are inevitable. If you don’t have someone to talk to it’s easy to back yourself into a corner, and that corner will get darker and darker for you.

Senior residents can help you map out a reading plan, navigate you through various faculty personalities and make sure that you’re checking the right boxes. A senior resident can also be your advocate to faculty and the friendship you develop will help you feel like you are part of the program, helping you build momentum through the years.

Mentorship with Faculty

Mentorship with surgical faculty is incredibly important at an early stage in residency. You may be born to do vascular surgery and it’s a sure fire career path or you may not know what field to choose. A surgical faculty mentor will help guide your career path, help you make important choices when it comes to quality projects and research years, serve as your advocate to other faculty and make sure you’re reaching your potential as a surgical resident.

The mentorship I had in general surgery residency and my research years guided me to pediatric surgery. Now as a surgeon with residents I have the tools and connections to guide them to their career of choice. Most surgeons, if they don’t have the knowledge or the connection will be able to help get you there with a phone call, a conversation or an email.

2.) Establish YOUR Reading Program

It’s a law: everyone learns differently and everyone learns at a different pace.

YOUR reading program will help you keep a consistent pace throughout residency and consistency is key.

Early on in my training a faculty surgeon gave me some great advice :

"Make a habit and get 30 minutes of reading every day, no matter what."

This advice is straight forward, easy and completely accurate!

I would set my alarm an extra 30 minutes early, make some french press and the reading begins. Every day I would move that bookmark along and eventually reach the end of the textbook. Then after a very brief pat on the back I move on to the next book.

Daily reading is a very useful habit, something I continue now. You can check out my post on the Miracle Morning to see how I incorporate reading into my daily routine.

In the posts that come I’ll put in my top reads for general surgery, again some are obvious and some are not.

Rotation Specific versus General Reading Plan

There is going to be rotation specific reading and general reading throughout residency. When you’re on colorectal you’ll want to read colorectal, when you’re on vascular you’ll want to read vascular. But using rotation specific reading for your education strategy will be jumpy and inconsistent. Jumpy reading will miss the foundational material necessary for a complete understanding of surgical disease.

Make a goal of dividing these two reading habits. The surgical education reading should be a long term strategy, it is a habit. Every morning or every night you commit to that reading habit. The rotation reading, for example can be done between cases or outside of that protected 30 minute window you are going to commit to doing, every day. Make the 30 minutes reading window a habit and you’ll peel through surgical textbooks at a remarkable rate. And when it comes to the ABSITE, I’m convinced that there is an almost direct correlation between reading and scores.

3.) Actively and Consistently ASK for feedback

I can’t tell you how many times the opportunity for feedback is lost. We wrap up the operation, the drapes come off, the orders are written, the patient is swept out of the room and the family is retrieved from the waiting room.

When does the feedback happen? It doesn’t…UNLESS you make it happen! Surgery training is about reflection, surgery training is above self improvement. This does not happen without honest and sometimes brutal feedback.

Right after an operation is when you need to debrief. A debrief needs to be an action on your part and it has to be deliberate. How did I do? What could I have done better? How could I have had more efficient movement? How do I set up my anastomosis so it’s easy? Why did you choose that type of suture or why did you do a sewn anastomosis? Why didn’t you leave a drain?

Plan your Debrief, Plan your Feedback

Every case is an opportunity for improvement…even just sewing skin. The more you do the simple things perfect the more translatable those skills will be on challenging cases. Surgery training is about learning and perfecting a simple set of skills. For example, “oh, it’s just an appy.” In that appy you learn to work with both hands, you learn how to position your trocars to make exposure easy. You learn how to position the patient. You learn how to manipulate the bowel. Importantly you learn how to apply tension to different tissues. You learn how to be delicate. You get to use an energy device in some cases and you get to learn how to manipulate the stapler. These skills are directly translatable to other more difficult cases. When you are doing your first laparoscopic duodenal atresia you appreciate having delicate hands, knowing how to apply tension, how to set up a good view, to use both hands and to manipulate bowel. Surgery training is not about the big cases, it is about perfecting the little cases so when the big cases come your skill set it deep with experience.

Remember, if something is hard you’re probably doing it wrong. Ask for help and ask for feedback. Once you’ve left the OR, THAT opportunity for THAT case is gone. The surgeon is most likely shifting focus to the next case, or the next family, project, meeting or responsibility. In addition the feedback you’ll receive is likely to be less specific and less helpful. For example, if you try to debrief after a whole day of operating it’s unlikely that you will have specific and constructive feedback to work on.

4.) Practice, Practice, Practice…and make it FUN

In residency my buddy Jorge and I would battle on the FLS machine. Who could get the blocks over to the pegs and back the fastest? Who could do their lap ties the cleanest and fastest. He always killed it and he would always remind me that I was seconds behind him. The competition made it fun, made it a game and made us both want to improve even if that meant just beating the other guy. Years in surgery training can be a long slog, so make it fun, go crush your mate in the lab.

Practicing your surgical skills in the lab, or in a homemade laparoscopic lab like this one will dramatically improve your operative experience. In the OR, on a patient, is not the time to be doing something for the first time. If you’re doing a laparoscopic case you should already be masterful at finding your hands, moving tissue, gently grasping or sewing. All of these can be done is a very basic simulator.

Build Foundational Skills

The details of the operation such as finding the critical view of safety in a laparoscopic cholecystectomy or trocar placement can not be learned until foundational skills are mastered. The better you are in the simulator the more confidence you’ll have in the operating room and the more progress you’ll make in an operation. You will find yourself less stressed when you know you’re going to whip down your knots deep in the pelvis, or sew up the Nissen wrap without difficulty.

When you struggle, when you fail to make progress, when you don’t have foundational skills, you will find that the surgeon takes over. As a surgical resident, there is nothing more frustrating than losing the case. You will lose confidence and that starts a downward spiral, especially for junior residents.

I can confidently say that as a teaching faculty surgeon, residents with good foundational skills make more progress in an operation, get positive feedback that is encouraging and this propels them to the next operation. Those residents without good foundational skills struggle in the operating room, become discouraged and this leads to a spiral of self defeat. You can build your skills in the simulator or sewing on a banana. Practice, practice, practice…and make it fun!

5.) Build the TEAM

One of my co-residents in general surgery is THE BEST at team building. She has an infectiously positive attitude that brings everyone together. Being on “a team” in residency made residency easy, we were all in it together.

You have every opportunity to be a leader, to bring people together, to help those residents who are struggling, to set the standard and bring a few laughs to rounds in the early dawn. You create the world around you.

If you can establish a team attitude and bring residents together you will find your residency experience can be a blast.

This may mean organizing some events together without the textbooks. Maybe it’s beers and ping pong in the backyard of someone’s house, maybe it’s ripping some turns together on the ski hill.

At the beginning of our chief year, my co-chief organized a rafting trip with the chiefs and the new interns. It was a blast. We camped, we had some beers, we floated the green river…it was an awesome team building experience and set the tone for the year.

6.) Find Projects, Follow Through

One of my mentors in pediatric surgery says “Don’t tell me you want to be a pediatric surgeon, show me you want to be a pediatric surgeon.” You show your interest by doing things above and beyond the check boxes and most importantly by FINISHING those things. I cringe when I think about all of the projects I flaked out on.

When I said yes to something and I knew there was no way I could get it done. While surgery training can make you feel like a yes machine, you don’t need to say yes to everything. Be honest when you’re being asked to do a case review you know you can’t fit into your schedule.

Be careful about biting off more than you can chew. As a resident you probably don’t want to get involved in a big prospective study.

You want to eat some low hanging fruit, maybe it is a a quality improvement project you identify that is interesting to you. Keep it simple and keep it focused. Present at your local university poster day or your regional ACS meeting.

Above all things, do not flake out, especially on projects and for surgeons in your career line. Finding success in surgical residency is partly the ability to be clinically proficient. It’s also the ability to identify projects and complete them.

7.) Challenge your Attendings and your Peers

Right now I’m reading an amazing book, The Challenge Culture by Nigel Travis . It is fascinating how challenge, or positive pushback, is a necessary requirement for success and growth in business. I think there are direct parallels in surgery and surgery training.

“Why” should be a very frequent word in the operating room. Why did you place the trocars like that? Why did you choose those trocars?

I utilized the word “why” a lot in surgery training but now that I’m an attending, I wish I had used it so much more! Find opportunities in M&M, in rounds, at the coffee shop and in the OR to ask “why”.

Don’t just accept something as gospel, given positive pushback.

8.) Find Balance in Surgery Training

I’m going to write an “Us and Them” post here shortly but the word “balance” is and was laughable to surgeons of previous generations. Some surgeons, while being absorbed in their careers, lost meaningful things in life that they could never get back. A marriage, relationships with their spouse or children, life experience.

They stand behind a “this is the cost” wall and actively avoid balance.

After finishing my first few years as as pediatric surgeon I can say that I’ve made considerable effort in finding balance. While being busy clinically and productive on the quality improvement side I’ve been able to get out of the hospital and live life. I have a close, positive and supportive relationship with my wife, I am present as a father to my three kids, I coach my son’s under 6 soccer team, I completed my first half Ironman during my first year as a surgeon and completed my first full Ironman during my second year on my 40th birthday.

Balance takes effort but that balance makes me a better surgeon. Surgery training can be very unbalanced. It is for all of us. Despite that feeling of unbalance, strive for balance. It will prevent burn out in the years to come, and it makes me a better husband and father.

Find Balance and You Can Have it All

In surgery training as a trainee it’s difficult to say no but remember this axiom: “You will never control your calendar until you learn to use the word “No”.” This is unbelievably true. You don’t need to go to that pharmaceutical or device company dinner, you don’t need to stay at the hospital just for the sake of staying. Get your work done, support your team and go home.

Find your balance wherever you can. For me nothing is better at the end of a tough day than going for a run with Lis or finding my kids and let them laugh and crawl all over me. For you that balance may be yoga, running, hiking, friends or art. Whatever it is, balance will make you a better surgeon and a better human. Check out my blog post on Finding Balance in Surgery.

9.) Write Down Your GOALS for Surgery Training

It doesn’t have to be on January 1 and it doesn’t have to be at an annual rate. Tony Robbins in the self improvement and business world comments “Failing to plan is planning to fail.” Surgery residency and medicine in general is a very overwhelming experience and it flies by in a moment. If you don’t plan out your training you will miss out on important experiences. Make sure, at the beginning of an arbitrary interval, say quarterly, you write down exactly what you want to accomplish.

For example, let’s say you’re beginning your intern year maybe you want to (1) finish the foundational chapters of Sabiston (2) identify a quality project of interest and (3) tie knots with both hands one handed, two handed, superficial and deep. Let’s say you’re ending your second year you may want to have a quarter’s goals be (1) confidently sew laparoscopically, (2) identify a research project and relevant scholarships such as the AAS or ACS resident research grants and (3) publish the QI paper from intern year.

Residency will go by in a flash and there are so many educational opportunities, especially if you put yourself out there and chase them down.

10.) The Glass is half FULL

This morning, probably 10 times or more as I greeted nurses, physicians and families through rounds in the hospital they would ask me “how’s it going doc?” and I always reply “Living the dream.” It has been my go to line for years, it’s positive, saying it makes me smile. Even if on a particular day it doesn’t feel true it reminds me that it’s a great privilege to be a surgeon for children and their families. I’m definitely living the dream. Check out my post on Optimism, Grit and Surgery and s ee what you think.

Be Gritty. Be Optimistic. Be Better. I think that’s a pretty good strategy, maybe even fit for a t shirt.

Going through residency you will have tough weeks, months, maybe even years for both professional and personal reasons. Through the long years of training you will also have a personal life that has stress. That stress may be relationships, finances, losing a family member, anything. And the stresses of the job and life can compound.

What makes this even worse is when a negative attitude sets in. You begin to bemoan your attendings, you complain about your junior residents or the nursing staff. You will find that others will jump in too and you all will be in a big complaining fest or pity party. Success in surgical residency will be hard.

Find Cues that Adjust your Attitude

Give yourself cues to remember that it’s a great privilege to be a physician and surgeon. You are here to do great work now and in the future. One of the things I start my day with is drawing my kids pictures to color. This morning, after Halloween, we transitioned from spooky ghosts to turkeys. It always makes me happy when I come home. My kids show me their colored drawings or how they’ve altered them.

During the day I have pictures of the fam at my desk that brings smiles. I have drawings from patients and thank you cards. Find your cues. Find those things that make you smile and help shift your attitude. You can turn to those cues during difficult days and realize that we have an awesome life.

A few thoughts and questions to close

What are some things that make you smile, laugh and recover from a difficult day?

Have you set your goals for this year? For your entire surgery training? For your early career?

What have you learned from your mentor this year?

Learn more, know less

citizensurgeon (Erik Pearson) — Mon, 02 Jan 2023 00:41:07 GMT

"An expert is one who knows more and more about less and less until he knows absolutely everything about nothing."

This morning I’m reflecting on the importance of humility and humbleness as we look forward in life to gain knowledge and experience.

As a surgeon I look at my profession and see that decisions are often being made based on dogma, past experiences, and training.

Are we asking ourselves, what do I know is right? Or what do I know as right and how can I make it better?

Learn more, know less.

I came across this reading an interview with Tim Ferris in Tribe of Mentors and I thought to myself, that’s a life lesson, that’s a life guide. It breaks down the longer more popular idiom from the American Philosopher Nicholas Butler who commented “An expert is one who knows more and more about less and less until he knows absolutely everything about nothing.”

How is this helpful as a surgeon?

As surgeons we should be constantly asking ourselves if the operation we’re going to do is not only the best decision for the patient but is the technique we’re about to use the best technique to achieve that particular goal.

Take cholecystectomy (an operation to remove the gallbladder).

Decades ago this was a morbid open procedure with a significant hospital stay. Surgical technique evolved to our current approach which is laparoscopic and it is supported by countless articles demonstrating less morbidity, less pain, less hospital stay, earlier return to function and the list goes on.

While cholecystectomy is the poster child, the same can be said for countless other operations across all surgical specialties from general and pediatric surgery to orthopedic, plastic, vascular, cardiac and others.

What I find interesting is not the before or the after but the in between.

In the famous book about change, Crossing the Chasm by Geoffrey Moore he presents the idea of behavior change related to different groups of people. There are the innovators and the early adopters who are responsible for paradigm shifts but then there is a big gap to reach the early majority.

That shift is the chasm, that shift is before the momentum and the research and the support has proven the superiority of a particular decision. Surgery is an excellent example of behavior change.

When it came to cholecystectomy, who were the early adopters, who were the innovators, and who now are the laggards?

While laparoscopic cholecystectomy is a great example of this in surgery it’s important to step back and see the pattern. What we “know” from our training as the best approach may not necessarily be the best approach or the best decision now. The pace of that change may take decades it may take years or it can be on a much more rapid timeline.

What are you learning now as “the best approach” and how could that change?

How are you putting yourself in a position to question, to improve, to learn?

Do you abhor change or do you welcome it?