Maintenance of Certification, Aging, & Our Patients

An article published in the Harvard Business Review set out to answer the question: “do doctors get worse as they get older?” With an aging population of physicians and the ever-changing nature of technology and medicine, it’s important that physicians maintain their clinical skills as they age. So what’s the best method for making sure that happens? We consider our options and make a suggestion in this blog article.

Current Standards

First off, let’s talk about the standards that are currently in place to ensure physicians keep up with the changing medical landscape. The American Board of Internal Medicine requires Internists to pass Maintenance of Certification (MOC) exams every 10 years in order to maintain their board-certification. Almost every surgical specialty has a different process for monitoring or mandating continuing education, certification, and tracking competency. But many are concerned that these assessments are not the best way to incentivize physicians to keep up with the latest technologies and improve patient care. Some have suggested a better way would be to measure patient outcomes. From the article:

“While there is some evidence that physicians’ clinical knowledge, adherence with up-to-date standards of care, and performance on process measures may wane as they get older, little is known about whether and how age impacts physicians’ practice and their patient outcomes.”

 
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Improving Performance & Outcomes

Even the methods for measuring our performance and outcomes is heavily debated. While it has not been well studied or reported on historically, patient outcomes have been shown to drop as a physician ages. There are many potential reasons for this, including:

  • It may be that many of us have difficulty adapting to change and older physicians may be last to adjust to advancements in technology.

  • It may be that some technical skills decline with physical decline, aging and mental processing delays, and each of us reaches a different tipping point where knowledge and experience overcomes these changes.

  • It may be that there are biases in the way the studies are performed.

When we go beyond understanding concepts of performance improvement as well as performance decline, my belief is that both are ideal for coaching. In many ways, we know ourselves best. We know the inner workings of our thoughts, feelings, and bodies. In other ways, coaching principles encourage one to receive constructive feedback, challenge thinking, ask empowering questions, and improve empathy in a more confidential and less judgemental environment. When you combine the expertise of a well-trained surgeon with that of a well-trained coach, the opportunities to improve and grow almost become endless. Whether early or late in one’s surgical career, most of us explore how and in what capacity we can apply our knowledge and skills to the benefit of ourselves and others.

What if our surgeons had coaches?

What if we used coaches to assist us to maintain and/or improve our skills?

What if coaches improved patient care, outcomes and experience?

SurgeonMasters is a physician coaching company delivering strategies tools aimed at preventing burnout and promoting wellness in the medical community. Have a suggestion for a blog article or podcast episode? Email Team@SurgeonMasters.com us to get involved!


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.

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