Training and Leading Physicians for the Fight Against Moral Injury

Note: This is part two of an ongoing blog series on burnout vs. moral injury. In the first installment, we learned that almost no one wins in our current system. Here, we will discuss how the Quadruple Aim is the most effective in achieving a more efficient and sustainable solution.

It is pretty clear we have an injurious healthcare system that overburdens healthcare professionals and under-provides for too many patients. The Triple Aim, Introduced in 2008 as a means to improve patient care, while commendable, fails to account for important players in the healthcare system. It is hard to argue that improved outcomes, better patient experience, and lower costs are important goals. If we were to achieve them our healthcare system would make vast improvements. The problem with the The Triple Aim is it doesn’t adequately address the full scope of the problem. In this article, we argue the Quadruple Aim is a better model for improving healthcare, and we offer three steps leaders can take in the fight against moral injury and burnout.

Post-Fight Analysis - Who Is The Real Opponent

In Part 1 the decision was unanimous - there is no winner in the fight arguing over the terms moral injury versus burnout. Instead, the fight should be against moral injury. The opponent IS burnout. With that in mind, how do we move forward? I strongly believe the path forward is to allow physicians to continue to fulfill their mission to provide high quality care (improve patient outcomes), to provide personal care (improve patient experience), and to encourage self-care, well-being, and anything that will enhance the healthcare professional’s experience or satisfaction. The fighter must be and stay healthy. If we are not healthy, how can we deliver the best care? If we are to encourage health for our patients, what if we actually modelled it?!

Once again, I commend the authors for advancing the discussion. The first key is to raise awareness and understanding.


 
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Training Physicians for the Future Fights

The second key to achieving the Quadruple Aim is training. How do we train and empower our physicians for future fights? Training physicians should be ongoing, rather than just at the beginning of a career. Training needs to include the awareness and understanding of burnout and the effects of moral injury. Training must include management as well as prevention of burnout. How should we allow rest and recovery in our “fighting” career? How does one dodge the punches, avoid the many cuts, and at worst, the knock-out blow?

In my opinion, training should include burnout prevention, self-care, wellness, and positive resilience training. Our existing training focuses way too much on negative resilience training techniques! Burnout is not a failure of resourcefulness or resilience. Burnout is the result of our resourcefulness and resilience at the expense of our own well-being and satisfaction.

The way to achieve wellness and healthcare professional satisfaction is to PRACTICE it.

Who are Our Coaches, Managers and Leaders?

The third key is that our leaders must embrace healthcare professional wellness and satisfaction. I agree with the authors that simple wellness programs and wellness officers will not solve the problem. I do know from my experience that mindfulness, positive resilience training, and forms of cognitive behavioral therapy are proven wellness strategies. The fighter will benefit by practicing many of these techniques that were not part of traditional medical training.

However, we need outstanding coaches, managers, and leaders who understand that physicians are not weak and do not lack resilience. We will see the greatest impact on wellness and burnout prevention when our leaders understand what causes moral injury and take steps to avoid the counterproductive actions that burden physicians. Establishing wellness programs and training wellness officers / leaders will be an investment of time, energy, and money to be effective. We must train wellness officers who are strong health professional advocates and enlist wellness programs that challenge old ideas.

It is time for our leaders to embrace the fourth aim and start championing physician well-being and satisfaction. If we do, we can reverse the current trends and fight moral injury and burnout.

If we do, patients, health professionals, and the healthcare system will win.

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.


How HPDE Helps Me Be a Better Surgeon

This guest blog was written by Dr. Lora Melman.

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.

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.

Tips for Becoming a More Resilient Surgeon

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Resiliency is one of the best ways to combat burnout in surgeons (and other professionals, for that matter). Many surgeons could improve their resiliency, which would insulate them from the symptoms of burnout. We need to encourage surgeons to build their resiliency and help them do it.

Before we get any further, let’s first define what we mean by “resilience.”  

At SurgeonMasters, we believe resilience can be defined in several ways. Resilience offers the ability to meet challenges and adverse outcomes as opportunities rather than barriers. It is fostered by self-awareness, confidence, preparation, a commitment to core beliefs, values and purpose. This article offers a few tips for becoming a more resilient surgeon.

Be Prepared for the Worst

Take steps to proactively prepare yourself for worst-case scenarios. Of course, it’s impossible to prepare for every possible situation that may occur, but laying the groundwork for recovery can go a long way. Being mentally prepared for change, and realizing that you can choose how to react can help you deal with bad situations when they arise.

Develop Emotional Self-Awareness

Having a good grasp on your emotional self-awareness is difficult for a lot of people, but it can help you understand yourself and others – especially in times of crisis. Take a good look at yourself and examine how you respond to stress, and what causes your stress levels to spike. This emotional  self-awareness can help you learn how to better react to and cope with difficult situations.

Understand Your Purpose

Understanding your purpose is an essential factor in boosting your resiliency. For many surgeons, their purpose takes the form of helping people and saving lives. For others, purpose can take the form of building and caring for a family. Finding your purpose is often easier said than done. But once you’ve found it, your purpose is a great foundation upon which you can build your resiliency. Having a good grasp on your purpose can give you perspective when things go awry.

Build a Resiliency Community

Building strong and healthy relationships with those around you (your family, friends, and colleagues) can help you in times of crisis. Having someone you can talk to, confide in, or commiserate with is much healthier than keeping things bottled up.

If you’re searching for a thriving community of like-minded surgeons, look no further than SurgeonMasters. We are a group of surgeons looking to build sustainable and lifestyle-friendly practices through resilience and wellness.

Contact us today to learn more about SurgeonMasters!

3 Tips for Surgeons to Promote Well-Being & Decrease Burnout

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In a March 2017 Forbes article, Paula Davis-Laack (Founder of the David Laack Stress and Resilience Institute) offers a few tips for promoting well-being and decreasing burnout in the workplace. I’d like to examine these tips and see how they relate specifically to doctors and surgeons.

Don’t Ignore the Problem – Acknowledge & Track

All too often, doctors who exhibit the classic signs and symptoms of burnout simply ignore the issue and keep pressing on with their work. But ignoring these symptoms does nothing other than delay the inevitable. Left unchecked, the stressors that lead to burnout will build and get worse. It’s a much better practice to acknowledge these symptoms when they arise and begin to track them. Do these symptoms crop up at a certain time of day, or when engaging in a certain activity? Measuring symptoms will help you identify the root causes of your burnout and help you achieve greater well-being.

Seeking Out Resilience Resources

Resilience is a learned skill that can be incredibly effective at keeping burnout at bay. Using various tactics, resilient people can develop an increased mental strength and toughness that can significantly help reduce burnout. Surgeons with high resiliency are much more likely to keep going when less-resilient people have already given up.

Finding Your Work / Life Integration (Rhythm)

Paula calls this “work / life integration” but I like to use the phrase “work / life rhythm.” Paula’s point is that efforts to integrate them will create more successful careers and relationships. My point is that our career demands are more successfully integrated when our other life responsibilities are addressed with quality and focus. I consider myself in my rhythm when I move from one role or relationship to the next with focus and quality in that role or relationship. This requires ongoing efforts, and the ability to say no when necessary.

Putting These Tips into Practice

Now it’s time to put these tips into practice! If you have questions about how to do that, or want to connect with like-minded surgeons about their well-being tips and tricks, subscribe to SurgeonMasters! With webinars, podcasts, and local meetups, SurgeonMasters aims to connect like-minded surgeons with one another and share tips to develop thriving and sustainable lifestyle-friendly practices.

Source: https://www-forbes-com.cdn.ampproject.org/c/s/www.forbes.com/sites/pauladavislaack/2017/03/06/organizational-strategies-that-promote-well-being-and-reduce-burnout/amp/

How to Manage Stress, Instead of Avoiding it

Photo by tetmc/iStock / Getty Images

Photo by tetmc/iStock / Getty Images

How to Manage Stress, Instead of Avoiding It

Stress is one of the primary contributors to burnout among surgeons (and other working professionals, for that matter). Most people try their best to avoid stress in their everyday lives. We’re constantly told to “live a stress-free life” – but that type of thinking is actually detrimental. Stress is a part of everyone’s life. Avoiding stress will only exacerbate and compound the issue. We’d be much better off by managing the stress in our lives, rather than outright avoiding it. In this article, we’re going to offer some tips for managing (instead of avoiding) stress as it arises.

Practice Healthy Habits

Doctors and surgeons encounter extreme levels of stress in their daily lives. When you’re literally holding a patient’s life in your hands, it’s no surprise that stress levels can be high. With such massive levels of stress, many people will turn to unhealthy habits in order to deal with their stress levels. Some physicians smoke cigarettes, or drink heavily, or eat a lot of junk food. These vices offer short-term stress relief, but are unhealthy and detrimental in the long-run. Try to combat these bad habits by forming healthy habits that reduce stress, like exercise, meditation, and socialization.

Sleep

A solid night’s sleep on a consistent basis is absolutely crucial to managing stress. We’ve all woken up after a poor night’s sleep and been irritable the entire day. Doctors often have to work long shifts at odd hours. That can lead to irregular and unhealthy sleep patterns. It’s amazing what a consistent sleep schedule can do to manage your stress levels. Do your best to create and stick to a sleep schedule by setting sleep goals for yourself.

Recognize & Address the Issue

Many surgeons bury their stress and go about their days as normal. When stress lurks below the surface, it’s bound to bubble up eventually and negatively impact your performance. It’s important to recognize stress and address it, rather than trying to avoid or bury it.

Got other tips SurgeonMasters should know about? Email them to us, Team@surgeonMasters.com.