How HPDE Helps Me Be a Better Surgeon

This is a blog from guest contributor, Lora Melman, MD FACS FASMBS.

My journey for continual learning started in medical school and pushed me through my surgical training. It didn’t become fun for me, however, until I discovered the sport of HPDE (High-Performance Drivers Education). Many of the tenets of HPDE can be directly applied to surgical practice. In this article, I’d like to walk through some of those connections and how HPDE helps me in my daily quest to become better as a surgeon.

What is HPDE?

HPDE, or High-Performance Drivers Education, is a driving sport that teaches awareness, car control, and how to approach “the limit”— the limit of what-physics will-allow-that-car-to-do-at-that-particular-part-of-the-racetrack-on-that-lap-on-that-day. The focus of HPDE is to learn your car, the racetrack, your personal limits, and to maintain the flow of traffic around the track.

HPDE is an extreme sport that requires preparation, concentration, the ability to maintain calmness, and a level of skill to maintain the margin of safety. Novice drivers are required to have an instructor until they are judged safe enough to go out on their own.

 
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Big Vision

The most important thing I learned on my first day of driving school was to always look farther ahead than I thought I needed to, so that I would have time to appropriately modify my inputs. By the time something is right in front of you, it’s too late to react—by looking as far ahead as possible, you can still see everything immediately in front of you and also see the important reference points coming up so there is no lost input information.

Anticipating and “looking” ahead is something we talk about in surgery all the time. From the initial “time-out”, to OR cards that detail to the room staff what to open and what to have available, to anticipating needs to minimize chaos in the room and staff turnovers during critical portions of the case – the list goes on. Seeing what may arise while progressing through the immediate steps of the case increases efficiency, reduces unnecessary delay under anesthesia for the patient, and leads to improvement in overall outcomes and productivity.

Mentorship

Being out of surgical training for several years now has taught me the value of ongoing mentorship, especially in a field where techniques, materials, and technology changes so rapidly that within a few years, things can go from cutting edge to almost obsolete. In residency, my mental “bandwidth” was so fully occupied with learning surgical management and memorizing exactly how each attending did each procedure, that I didn’t pay attention to how my skills were changing and growing. Now that I am in practice, although I am eternally grateful for the excellent training background I received, there are days when I wish I could intraoperatively “Face-Time” one of my mentors to pick their brain about a no-way-to-predict-this-question-preop-haven’t-seen-this-before-what-they-would-do-now-in-this-particular patient-regarding-this-particular-issue question.

No matter how you choose to care for yourself don’t be afraid to think of it broadly. There are a million ways we can improve our wellness while at conferences.

Learning to Drive Solo

After I graduated from novice HPDE group, I drove in Intermediate Solo (no instructor), and now am in Advanced Solo. There are many times I wish I still had an instructor in my right seat for immediate feedback for what I could have done differently. Sometimes I wonder what pearls I’m missing out on, yet 100% instruction at the upper levels of training is something that is just not realistic and/or achievable for the majority of participants in the sport, so we do our best, and try to set our own goals for improvement. Just as I am not done learning new things on the racetrack, I am continually learning new things as a surgeon.

I am one that believes there is no such thing as “natural inborn” talent, but rather that talent is the result of the right combination of personal drive to be better, willingness to work hard and push through difficulty, and an accumulation of previous skill “programming”. Deliberate slow practice of the sub-components and the process of mindfulness in repetition builds the circuitry that allows a tennis champion to predict where the ball is going to be, a musician to sculpt their performance, a race car driver to achieve a successful overtake, and a master surgeon to see the proper plane(s). The ultimate challenge, then, is to develop the correct skill set for the intended goal with the best possible mentorship available, and to maintain an insight on your own progress.


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Lora Melman, MD FACS FASMBS

Dr. Melman is a board-certified minimally invasive and robotic surgeon with a private practice in Central New Jersey. Her areas of expertise include Fast-Track Surgery/ERAS—the methodology of improving surgical outcomes and decreasing postoperative recovery times, repair of all types of abdominal wall hernias, sports hernias, and diaphragmatic hernias, treatment of reflux disease, and surgical weight loss for obesity. She is a widely published author of peer-reviewed literature on hernia mesh and biomaterials. She also has a special interest in studying safety, performance, and team dynamics based on principles used in the motorsports-racing world. Dr. Melman's series: "Surgical Lessons from the Racetrack", runs weekly during the summer season and explores the overlaps between the art of Surgery and the science of High Performance Driving.

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Make Time for Wellness During Conference Season

If you are like me and many of the physicians I know, you’re often attending conferences in spring and fall. Travel can be stressful and often we would rather be home with family, but there are still ways to create opportunities to recharge and improve our wellbeing while we’re away. In this article, I would like to offer a few simple things we can do to improve our mental health and wellness as we go through another conference season.

 
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Set Personal Learning Objectives and Goals

We all attend meetings with program learning objectives telling us what we will learn and how we will improve our practice. I find that conference objectives don’t always align with my greatest needs. Before you go, I encourage you to reflect on YOUR greatest needs and write them down as personal learning objectives and goals. It can be as simple as a list of things you would like to accomplish by the end of the meeting. Be sure to check them off as you go and include the next steps as to how these will be transitioned into practice back home.

Create Opportunities for Self-Care

I think of opportunities for self-care very broadly. Basically it can include anything that impacts our physical or mental well-being. Here are three simple suggestions for self-care at conferences:

  • Disconnect - Strategically turn off email, phone, social media, and any other intrusion when you can. Even if it is for 5-10 minutes at a time, that’s 5-10 minutes of mental rest you didn’t have before.

  • Sleep - Sleep can be hard to come by in our busy lives and at conferences. We learned in Episode 35 of the MIni-Podcast Sleep Hygiene! that it is possible to catch-up on sleep, and improve our health in the long term. Take a nap, go to bed early, or sleep in later than usual. Find some way to manage your sleep hygiene.

  • Exercise - Inject physical activity into your conference experience. For me, it’s yoga. I love that conferences more and more are offering events like yoga and 5ks. Even if they aren’t, consider taking a few hours to go for a hike or play the golf course on the property. I will often find a local yoga studio to practice, if the conference isn’t offering it.

No matter how you choose to care for yourself don’t be afraid to think of it broadly. There are a million ways we can improve our wellness while at conferences.

Connect with Colleagues and Friends

One of the items on top of your list should be to connect with colleagues and friends. Take this time to reconnect with colleagues from medical school, residency, fellowship, and other points in your career. Peer support is a powerful tool for improving and maintaining our well-being. There’s no better time to connect with others who understand the challenges we face regularly than during conference season.

SurgeonMasters is building a community of surgeons and physicians offering peer support and camaraderie. Reach out to Team@SurgeonMasters.com to contribute.

How to Help Recognize the Signs of Burnout

It is well known these days that burnout is a widespread point of discussion in the medical community – especially among surgeons. As much as we talk about it, many physicians don’t even realize that they’re burned out. We talk a lot about how surgeons can prevent and treat symptoms of burnout when they arise, but an essential first step in that process is getting the burned out surgeon to realize that they are experiencing burnout. In this article, we are going to address this issue and offer some tips for helping surgeons recognize the signs and symptoms of burnout so they can take appropriate action.

 
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Demands of the Job

The system and culture expects a lot of our physicians – too much, in fact. Many of us were trained to power through adverse situations and solve problems on our own, without asking others for help. The strategy of working harder and longer does nothing to improve our situation. Rather, it leads to unprocessed anxiety, stress, and fatigue – classic symptoms of burnout.

Burnout is not typically caused by a single event. It usually builds slowly over the course of months or years, much like the frog in the boiling pot – making it even more difficult to recognize and address. When we do finally exhibit the signs, it is important to effectively identify them as such.

Recognizing the Signs

Keeping an eye out for red flags is an important first step. Even asking simple questions can bring heightened awareness to our current situation.


Here are three simple questions you can start with.

Do you find yourself or a colleague “checking out” or disengaging from patients?
Do you find yourself or a colleague overwhelmed and disengaging from family, friends, or colleagues?
Do you find yourself or a colleague losing the joy of your (their) career and accomplishments?

These signs can be hard to recognize in ourselves, so it’s also important to keep an eye on our friends and colleagues as well. If you notice any of these red flags in a friend or colleague, go beyond asking them how they’re doing and if they need any help. Most will say they are fine and “no thanks.” Come at it from the side of compassion. You could offer support in ways that you might want others to give it to you, or you could share with your colleague one of our resources, blogs, or podcasts that really resonated with you.

SurgeonMasters Wellness & Resilience Services

At SurgeonMasters we are focused entirely on the wellbeing of surgeons and physicians. We offer a variety of educational resources (educational programs, coaching, articles, podcasts, etc.) aimed at equipping physicians with tools and strategies to improve well-being and increase resilience. We are building a community of surgeons and physicians offering support and camaraderie. If you are not currently subscribed, add your name to the mailing list and send us a note to say hello or provide your thoughts.


Source - Helping Physicians Recognize They're Burned Out, Steph Weber, Physicians Practice, April 9, 2018

Burnout vs. Moral Injury - And the Winner Is ...

Note: This is part one of an ongoing blog series on burnout vs. moral injury. This first installment dives into moral injury as a concept and how it differs from burnout. In part two, we will discuss managing improvement through the Quadruple Aim rather than focusing solely on patients and “the bottom line.”

A popular article published in STAT argued that physicians today are not suffering from burnout, but rather “moral injury.” From the article:

“Physicians on the front lines of healthcare today are sometimes described as going to battle. It’s an apt metaphor. Physicians, like combat soldiers, often face a profound and unrecognized threat to their well-being: moral injury. Moral injury is frequently mischaracterized. In combat veterans it is diagnosed as post-traumatic stress; among physicians it’s portrayed as burnout. But without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.”

 
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The authors’ perspective on "moral injury" is valid. My added perspective is that physicians are very well trained in NEGATIVE resilience and poorly trained in POSITIVE resilience. There are so many viewpoints on this topic, and I believe the vast majority are truthful. Certainly, the article’s popularity confirms that the concept of burnout may not resonate with many physicians. There are so many health conditions that have been described with different names or terminology. As physicians, discussing mental and emotional issues with patients comes naturally to us. Turning the lens on ourselves and our colleagues is more difficult. Our lack of self-awareness, our competitive nature, and our negative perception of the word burnout could all explain the lack of resonance of “burnout” with physicians.

The Weigh-In - What the Literature Says

We certainly do not need to be stuck in the old literature, in which Maslach defined burnout as a series of symptoms including emotional exhaustion, depersonalization (or cynicism), and a decreased sense of personal accomplishment. Much has been learned about burnout over the last few decades. If you are interested in a deeper dive, feel free to check out the article Understanding the burnout experience: recent research and its implications for psychiatry by Christina Maslach and Michael Leiter. Burnout is not a failure of resourcefulness or resilience.

Moral injury in medicine is described as the failure to consistently meet patient’s needs or to provide high-quality care. It results from highly conflicted allegiances to patients, organizations, and self.

While I personally believe that you don’t have to measure everything in medicine in order to manage change, many of those involved in healthcare, including a lot of physicians, want to follow the science. For those, we need to be measuring something and tracking the effectiveness of our interventions. One can attempt to measure resilience, attitude, productivity, and much more. There are many available assessments that can help - such as the Maslach burnout inventory and the Physician Well-Being Index.

Moral injury in medicine is described as the failure to consistently meet patient’s needs or to provide high-quality care, and one that results from highly conflicted allegiances to patients, organizations, and self. In part two, we will discuss managing improvement through the Quadruple Aim rather than focusing solely on patients and “the bottom line.”

Scoring the Fight - Who Wins

All of these descriptions of “the problem” are valid. Currently, I am not aware of an assessment tool to measure moral injury, or the number of repetitive cuts that one can endure before healing begins or recovery is no longer possible. If we want to find solutions, what if we moved past which words are better? Resilience? Burnout? Well-being? Moral injury? I am passionate about working on them all, for “I do what I do to make a major positive impact on other people’s lives.” I am willing to measure subjectively, rather than just objectively. Many in our healthcare system want or demand an objective measure. Without an objective measure of moral injury, we may need to continue to measure burnout or well-being.

I commend the authors for a very well-written article. When the system is burning out or morally injuring surgeons, physicians, and many others in healthcare, who is the winner?

No one wins.

Let’s change the system in many ways and keep supporting each other as we do it together.

SurgeonMasters is building a community of surgeons and physicians focused on changing the practice of medicine. Email Team@surgeonmasters.com to contribute your voice to the conversation.


Source - Physicians aren’t ‘burning out.’ They’re suffering from moral injury, By SIMON G. TALBOT and WENDY DEAN, JULY 26, 2018.

Weaponized Praise Does Harm in Healthcare

Weaponized praise is an unfortunately common tactic used by many leaders and administrators in the healthcare industry to manipulate physicians and even other healthcare professionals into doing more work, often in lieu of a raise, a promotion, or helping us solve our most pressing issues. I also think that there is a more sinister twist to how it is used against physicians.

Weaponized praise is a pervasive tool used in medicine by most leaders and the entire healthcare system. I would describe the technique of weaponizing praise as leveraging a doctor’s ethics and drive for quality and the passion to provide patient care. In fact, I have been victim to this and I see many other victims, where the praise is weaponized to get doctors to make up for the failings of a system.

In my first job, I was given titles and lots of praise. For a while, I responded to it with increasing case volume and continued effort to receive that praise. It was confirming of my worth as a physician and provider of care. Within my second year, I had the second highest RVU's (a measure of productivity) in the department. I responded to the praise by picking up other people's responsibilities.

I received encouragement to delegate more, whether to the residents or to my administrative assistant, but I was not guided in the process of HOW to do that.

I was added to committees. I had ever increasing responsibilities.

 
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This might describe almost every early academic career. It is a common tactic for onboarding others in private practice as well. When it comes to raises or promotions, I was told that it was beyond my boss's control. Promotions had to go through the university process. Appropriate raises were just not possible due to departmental financial constraints or the shrinking dollar in healthcare.

Sounds like a flawed process.
Sounds unsustainable. And it was.

When I finally started adjusting my work schedule to more sustainable levels, the only thing that seemed to change was that the praise went away.

I think that navigating this complex dynamic would have been easier with professional coaching. It is a balance between operating at high performance and the understanding that simply taking on more work does not necessarily equal greater results. Creating efficiency and building strategies to develop a lifestyle-friendly surgical practice that is sustainable would be a more effective process. If I was taught then the 8 PRACTICEs of Highly Successful Surgeons, and if I was provided coaching, I might have stayed in an academic practice. I know I would have been much further along in my career growth. Knowing how to operate and take care of patients is simply not enough.

So what are the shields and opposing weapons to this kind of weaponized praise?

“Accept your boss’s praise. Politely decline extra work, and try to offload what you’ve already taken on.” - Jessica Wildfire

In a recent article on the topic, Jessica Wildfire outlines the following recommendations for combating weaponized praise:

  • Accept the praise

  • Don’t whine about doing extra work

  • Politely decline extra work, and even try to offload what you’ve already taken on

  • Learn and implement a strategy to say “no”

  • Highlight your desire to do high quality work

  • Remind your boss of what you are already doing

  • Only take on projects that will raise your knowledge or value**

  • Find out who should actually being doing the work and redirect

  • Doing extra work should eventually lead to some kind of reward

Each of these tips has potential value. Most are often part of an overall strategy of learning to say “no” and setting priorities.

**Since many physicians want to gain new skills and knowledge, one needs to proceed here with caution. There must be a limit to the work or the timeframe over which it should be completed. Research notes that rest and recovery are necessary in between these periods of challenge. Has your boss accounted for that?

We can certainly challenge ourselves. Research shows we often grow the most when we are challenged just outside our comfort zone. Your boss might not have a clear picture on where that threshold is for you. You might not even know that threshold yourself. Are we being realistic with ourselves that the increased value and reward will be achieved? Could it be done over a more realistic timeframe?

I hope you can incorporate some of these tips into your shield against weaponized praise.

If not, these challenges are a great reason to use a coach.

SurgeonMasters is building a community of surgeons and physicians looking to change the culture in medicine. A coaching mindset and skills are powerful tools to start creating the change we need. Email Team@SurgeonMasters.com to get involved.

Source: Watch Out for Weaponized Praise