|Year : 2019 | Volume
| Issue : 1 | Page : 1-11
What's new in academic medicine? Things we wish were taught during our medical training
Harry L Anderson III1, David P Bahner2, Michael S Firstenberg3, Sagar C Galwankar4, Manish Garg5, Sona M Garg6, Donald Jeanmonod7, Rebecca Jeanmonod7, Lorenzo Paladino8, Thomas J Papadimos9, Stanislaw P Stawicki10
1 Department of Surgery, Division of Trauma and Surgical Critical Care, St. Joseph Mercy Health System, Ann Arbor, Michigan, Columbus, Ohio, USA
2 Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
3 Department of Cardiothoracic Surgery, The Medical Center of Aurora, Aurora, Colorado, USA
4 Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Sarasota, Florida, USA
5 Department of Emergency Medicine at Temple University Hospital, Philadelphia, USA
6 Department of Occupational Medicine at Einstein Medical Center Montgomery, East Norriton, Bethlehem, Pennsylvania, USA
7 Department of Emergency Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
8 Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
9 Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, Ohio, USA
10 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
|Date of Web Publication||23-Apr-2019|
Dr. Stanislaw P Stawicki
Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Anderson III HL, Bahner DP, Firstenberg MS, Galwankar SC, Garg M, Garg SM, Jeanmonod D, Jeanmonod R, Paladino L, Papadimos TJ, Stawicki SP. What's new in academic medicine? Things we wish were taught during our medical training. Int J Acad Med 2019;5:1-11
|How to cite this URL:|
Anderson III HL, Bahner DP, Firstenberg MS, Galwankar SC, Garg M, Garg SM, Jeanmonod D, Jeanmonod R, Paladino L, Papadimos TJ, Stawicki SP. What's new in academic medicine? Things we wish were taught during our medical training. Int J Acad Med [serial online] 2019 [cited 2019 Nov 12];5:1-11. Available from: http://www.ijam-web.org/text.asp?2019/5/1/1/256795
| Introduction|| |
For the April 2019 issue, the Editorial Board decided to focus on perceived gaps within both undergraduate (UME) and graduate medical education (GME) curricula. Consequently, we present our readers with some unique perspectives, assembled into a collection of experience-based “pearls” or testimonials by faculty with at least 10 years in active clinical practice from across a highly diverse group of academic institutions. Our overarching goal is to help identify opportunities that will make our UME and GME systems stronger and help better prepare our medical students, residents, and fellows for effectively managing both the cognitive/physical rigors of modern clinical practice and enhanced proficiency across other important domains of one's daily functioning. The topics discussed by our team are complex, as reflected in the word cloud provided in [Figure 1]. We hope you enjoy the read and find some of the shared experiences helpful.
|Figure 1: Word cloud illustrating both the complexity and heterogeneity of topics discussed in this article. Current medical school and residency curricula tend to focus on technical and knowledge aspects of training, with many important areas identified as “blind spots” by the current expert panel|
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| Pearl #1: Leading from the Front, Leading by Example|| |
I was fortunate in my training that critical and independent thinking was emphasized, along with a small but healthy dose of skepticism. Although this approach was applied rigorously to the “statistics and methodology” of the monthly journal club during residency, it would behoove rising physicians to also apply critical thinking and common sense to policies and procedures where they practice.
As the face of our profession evolves due to both internal and external pressures, we often find ourselves governed by those who do not operate in the same environment. This precludes the important principles of leading from the front and leading by example. Sometimes, proposed institutional changes are of great benefit (i.e., hand washing vigilance), but many times, they are not (i.e., routine blood cultures in pneumonia). Making sure new policies are grounded in evidenced-based practice before they are implemented is not only best practice but also prevents diverting and wasting of resources and lends to a credible track record in the long term. Every road to success will have its failures along the way. However, how often failures happen and how rigorous a vetting each policy undergoes to determine that it will indeed address and affect the desired outcome variable are hallmarks of good policy makers and implementers.
Communicating with those in the trenches is a necessary step, but it is also important for leadership to experience the trenches. It is here that the good idea fairy meets what works, was does not, and what needs to be refined further. Leadership from those who “do” is also advocacy.
| Pearl #2: the Clinical Foundation of Medical Education and Leadership|| |
Medical school is an opportunity for higher learning where very bright students become accustomed to a whole new language. Some refer to this language as “medicalese” or “doctor speak.” It has been estimated that 15,000 (or perhaps even more) new words are learned, and this amount of new material can almost double a person's existing language. Becoming a clinician and mastering this “new language” is first and foremost the most important part of medical school, and it can be daunting with the overwhelming amount of words a student has to master. It is important to learn not only how to speak this language with other doctors, nurses, and health-care personnel but also how to translate it back into a language that a healthcare-naïve person can understand. Practical implication of the above is that all of us may become patients at some point in our lives, and thus, being able to communicate clearly and effectively is paramount.
The experience of medical school can be very daunting, with multiple competing priorities “thrown” at the learner. As a result, many students experience an imposter syndrome where the overwhelming nature of the totality of medicine can contribute to a sense of insecurity among the less-experienced team participants, especially when applying newly learned skills in front of patients/families or medical teams. Being true to self, being humble, and developing a professional identity are all important during this time of transformative growth. Establishing one's clinical knowledge and the ability to communicate with patients – as fellow human beings with compassion and empathy – is the primary purpose of medical school and the first step toward professional leadership.
Determining what type of physician to become and which specialty is right for you are among some of the hardest decisions medical students will have to make. Reading the professional journals from the field(s) one is potentially interested in provides a critical insight into the current issues facing a particular specialty or discipline. If the student wants to explore a specific area of expertise further, they should join the corresponding professional organization as a student member. Student membership pricing is usually discounted and allows early entry into the professional world of specialty medicine. The act of joining a national medical organization is an important step in leadership development, professional growth, and meaningful participation in the community.
According to an old proverb, “getting started is half the battle.” This is indeed the case, and one quickly realizes that professional and personal development truly starts on “day one” of medical school. As one progresses through medical school and increasingly acquires knowledge specific to their area(s) of interest, he or she can then choose to either strengthen the commitment to a particular field or find another focus area. As stated above, early immersion in discipline-specific journals provides tremendous insight and helps determine one's ultimate career destination. Moreover, listing the participation in interest groups and journal subscriptions on one's evolving curriculum vitae demonstrates early allegiance to the specialty and may help on future interviews, many of which will feature the standard question, “why do you want to go into this field?” Finally, ample opportunities for student leadership in professional organizations exist. After all, engaging medical students provides a solid foundation for future growth of the professional group or specialty in question. In a complementary way, getting involved in the specialty as early as possible is an important part of medical leadership development.
Curiosity, openness to new ideas, actively working with others, as well as challenging (in a polite way) existing dogma are some attributes of leadership that are especially important in the current dynamically evolving world of health care. A typical medical school offers numerous extracurricular activities and projects, including various research opportunities. Researching new knowledge allows one to understand past problems any current challenges, and ultimately leads to progress through hypothesis-driven solutions as the basis for a better way to do things in the future. Purpose is the key to success, yet it may take years of deliberate practice to learn how to focus, plan, and effectively execute projects. Finally, being curious and asking questions are signs of a good leader, and seeking to better understand the forces that shape our lives is the most important step toward true knowledge.
In summary, this advice translates into being true to oneself, doing what is right, and proactively establishing one's clinical and professional foundation in medicine. This begins with expanding one's knowledge horizons beyond the classroom instructions (e.g., reading medical journals) and becoming actively involved in various specialty organizations. Finally, being inquisitive, flexible, and open to new ideas facilitates professional growth and leadership development. Medical students are encouraged to maximize all available opportunities to develop their professional identity and prepare for leadership within the health-care industry of the future.
| Pearl #3: Focus on Clinically Relevant, Evidence-Based, Up-To-Date Information|| |
In medical school, we were taught knowledge which was compiled into masterfully edited textbooks. However, even the most recently released books contain information that is relatively dated, usually by at least several years. Given this important observation, I wish that medical school curricula were re-evaluated more frequently and contained more up-to-date information. In addition, such information should be taught with emphasis on practical and clinical applications., This is especially relevant in the context of “clinical practice readiness.”, Technology plays an increasingly important role in the bedside practice of medicine, including the now widely accepted electronic medical records. In retrospect, I wish we were better trained in using technological health-care tools in a more extensive way. Keeping with times, medical schools and residencies alike should incorporate into curricula information regarding cutting edge health-care innovation, such as artificial intelligence – a rapidly growing area that will likely have profound impact on how we practice medicine in the future. Finally, my medical school education featured very little training on business of medicine and medicolegal aspects of practice.
| Pearl #4: the Importance of Occupational Hazards and Work Safety|| |
Sharps injuries, fluid exposures, and occupational hazards are subjects I wish were discussed more thoroughly during my medical training. The impact of a needlestick or occupational injury has repercussions for a hospital's most valued resources – the employees. Understanding the statistics and the proper hospital procedures for addressing such injuries is vital to the health and well-being of both an organization and its employees.
Sharps injuries account for 385,000 hospital-related exposures according to the Centers for Disease Control and Prevention (CDC). The risk of obtaining human immunodeficiency virus (HIV) via needlestick from an HIV-positive patient is approximately 0.3%, hepatitis C from a hepatitis C-positive patient is about 1.8%, and hepatitis B from a hepatitis B-infected patient ranges from 6% to 30%. Hospital protocols may vary, but procedures for reporting should be available and clearly communicated to all hospital employees and rotating staff, including medical students and residents.
Documenting the incident via an incident reporting system, followed by an evaluation by a trained employee health clinician, should be performed as soon as feasible. Recording the type of needle including the manufacturer, size, shape, and whether a safety device was engaged or not is important for Occupational Safety and Health Administration (OSHA) mandated reporting. Documenting the body part affected, the location of the incident, what medication was being administered, and whether the sharp was part of a kit are also important to authenticate. Employees should have updated tetanus and hepatitis B titers on file. Having an established protocol to draw the source's laboratories including HIV Ab/Ag, hepatitis C Ab, and hepatitis B surface antigen HBsAg can alleviate anxiety about source blood transmission. Drawing a patient's baseline laboratories such as HIV Ab/Ag, hepatitis C Ab, and HBsAb is an important next step. Offering postexposure prophylaxis when appropriate and having a corresponding “starter pack” in the occupational health office can give employees psychological respite when injured with a sharp from a known HIV-positive patient.
The psychological strain of needlestick exposures can affect employees' enthusiasm, morale, and adversely impact their professional performance and career. Fear of being exposed to lifelong infectious agents in the midst of caring for other people's health can cause significant anxiety and stress. It is imperative that health-care professionals receive appropriate counseling and feedback from a trained occupational health clinician to mitigate fears and improve understanding at the time of these incidents. In my practice, I recommend that patients should immediately follow up with me in my office to expedite source laboratory work collection, acquisition of appropriate laboratory work from the patient, as well as any required counseling. Discussing patient fears, emotional health, and what to expect throughout the process is vital. Notification of laboratory results as soon as they are ready helps alleviate patient fears.
Preparing trainees and employees by communicating appropriate procedures to follow after an occupational injury can expedite treatment, decrease stress, and promote wellness in hospitals and other institutional settings. Prevention is critical, including the teaching of enduring methods (i.e., lectures/simulations/sharp safety mechanisms) to avoid sharps injuries and occupational hazards in the first place. However, when these events do occur, having onsite employee health clinicians to address incidents immediately can make a tremendous positive difference.
| Pearl #5: Physician Employment and Negotiation – “the first Contract”|| |
One of the most intimidating and misunderstood aspects of a career in health-care is the employment contract. There are some protections afforded by the Accreditation Council for Graduate Medical Education for a transitioning 4th year medical student (as they begin residency) or resident (as they begin an accredited fellowship). Many of those protections disappear once the day arrives when the trainee is handed a proposed multi-page employment contract for work as a licensed physician. The potential employer might be a private hospital or health system, affiliated with a university or even an independent group of physicians, and the employment contract will dictate what the prospective new physician must do (and not do), and what remuneration/benefits he or she will receive for doing it. There are some good primers and reference guides on negotiation and contracts offered by many of the specialty societies and prominent law firms, with a few helpful examples referenced herein.,,,
Medical schools typically do not teach employment or contract law to medical students, and only very basic information may be gleaned during postgraduate training through lectures by faculty mentors and invited experts. Occasionally, representatives from physician-hiring organizations or law firms will volunteer to provide “informational lectures” to physicians-in-training, and these free lectures can be very helpful as one begins the quest to find a position at the start of a medical career. Federal employment laws certainly dictate what can or cannot be part of the hiring process or the employment contract, and employment laws may also vary by state., Yet, the fundamental nature of a “contract” as a “private document” must be emphasized. Understanding the many nuances of an employment contract is really beyond the expertise of most health-care providers. It is surprising how many physician applicants, after arriving at a mutually agreeable salary, will enthusiastically sign the contract when first placed before them. The physician may also be told that the contract is “boilerplate” or “corporate standard,” and changes cannot be made to the document. More often than not, this is either simply not true or frankly represents a “lazy truth” intended to minimize the overall work/effort of the corporate counterparty.
From an employer's perspective, there are required portions of the employment contract which are needed to accomplish the employer's business mission, to conform to applicable state or federal laws, to help streamline operations, and to legally protect the employer. It should therefore be of no surprise that the wording of the contract will invariably be weighted in favor of the employer, and not the physician employee, especially if any potential or subsequent disagreement arises. As trainees complete postgraduate training, the attractiveness of a “real salary” is very enticing, and there is motivation to move and “sign” quickly. However, it is recommended by this author that before signing any employment contract, the expertise of an employment attorney, particularly one versed in health-care employment law, be sought as one prepares to agree to the terms of employment with a future employer. There will certainly be an out-of-pocket cost to the physician applicant, and a prospective employer will not (and probably ethically should not) pay for it. Enlisting relative or friend who is an attorney will certainly be financially attractive, but such an arrangement can be problematic since there may be no established attorney–client privilege. The employment attorney is your legal representative in this process. The review process can be often conducted by E-mail or over the telephone, and it should be the goal of the process to identify any problematic/questionable or illegal content in a proposed employment contract. The attorney may request a modest retainer to begin work on the contract, and like anything else, this should be negotiated to be reasonable and limited in scope and cost.
The negotiation process doesn't end as the contract is first delivered to the physician applicant, as now identified problem areas in the draft contract may similarly require additional negotiation. Having the employment attorney do the back-and-forth of negotiation seems attractive, but that luxury will be much more expensive. A better approach is to have the attorney identify the concerning areas of the contract, which will then allow the physician applicant the opportunity to negotiate directly with the potential employer. Approaching the employer with dispassionate dialog and negotiation is helpful not only to the employer – they will get an early sense of the physician applicant's demeanor and level of business knowledge, if done professionally – but also to the employee, who will get an immediate view as to whether the employer is reasonable, and will negotiate fairly, etc., Each party has motivation to be respectful during this preliminary process since a desired commitment between both parties could still be at risk. You should be aware of and (hopefully) agree to each and every aspect of the final employment contract that you have negotiated for, and are about to sign. Should there be a true impasse in this final step; this is the ultimate opportunity to reconsider aligning with an employer who is inflexible or unreasonable with something that you and/or your attorney has identified as important or problematic. In such cases, you may need to ask yourself, “Do I really want to work for this particular employer?”
| Pearl #6: the Ability to “walk Away”|| |
My first job out of residency was with a self-reported democratic group, where decisions were made by the group, for the group. The caveat to entry into the democracy was the investment of time. While the time passed, I found myself working more and more nights and weekends. Although reimbursement was disproportionately favorable for partners of my group, in the end, I decided that this does not truly make me happy and anything else was better than my status quo at that point in my career. Although that first job lasted only about a year, for the first time in my life, I realized the importance of the power to “walk away.” It is a scary thing to give up what you know for the unknown, but life is short, why endure something that you find loathsome.
The recurring theme throughout my career is that the person with the greatest amount of leverage is the one who can walk away from the negotiating table. After years at my next job, the department implemented a computerized scheduling device. I had invested time and was established within the group. I had risen to a position of leadership, but after several months of an unworkable schedule, advising the administration of my discontent, and the subsequent inability or unwillingness to fix the problem, I walked away. Our family was young and established in school. The housing market to sell our house was poor. The timing wasn't right. All sorts of things were perceived barriers to moving on. In the end, my next job was better.
It is my current job. My colleagues are great. Our school system is good. My family is happy here. If things changed and it started to not work for me, I would try to fix it. But if it became unfixable, I know that I still have the choice to walk away.
| Pearl #7: Learn, Embrace, and Practice Emotional Intelligence|| |
I graduated from medical school in 1978, or approximately 17 years before Daniel Goleman's seminal work, “Emotional Intelligence,” was published. Emotional intelligence (EI) is a topic of which all leaders in and out of academia should be aware. If it had been part of my professional training curriculum, I would have benefitted greatly. In our daily practice of medicine and interactions with patients, their families, administrators, and colleagues, perceiving emotions, using emotions, understanding emotions, and managing our emotions and those of others would greatly enhance productivity, efficiency, and satisfaction.
Goleman has produced work showing that EI accounts for approximately two-thirds of a leader's capabilities and effectiveness; it is much more important than the traditional intelligence quotient or technical expertise. Understanding one's own EI capabilities will enhance a leader's competency in regard to empathy and self-awareness. If an individual understands their EI capabilities and opportunities, they can adopt an effective leadership style in their current working environment. Moreover, and related to some of the pearls discussed earlier in this article, if an individual understands his or her EI capabilities and shortcomings, they can avoid taking jobs or leadership positions for which they may not be well suited. In addition, those who are hiring leaders for their organization would also do well to choose individuals who represent a “best-fit” for the workplace and for interactions with management. A better understanding of my colleagues, foes, bosses, employees, and patients, through EI, would have better served me, the organizations with which I was affiliated, and my general societal setting.
| Pearl #8: Effectively Approaching and Managing “difficult” People|| |
This is a very difficult – and quite frankly – a fairly “loaded” topic. The answer also depends on one's current and past perspectives, life experience, and personal growth. For me, the current set of most formidable challenges revolves around leadership and advanced “people skills.” Given my personal and professional experiences, I firmly believe that neither medical nor business education (I am fortunate to have both) prepares one adequately to effectively deal with the so-called “difficult person” or someone whose expectations and behaviors are inflexible and very self-centered, full of entitlement, and at times not well intentioned.
Throughout our careers, most of us have heard statements along the lines of “…this person is difficult to deal with…” or “…it's just the way they are…” or perhaps “…things just seem tense around this individual.” In some instances, entire teams of people would literally “walk on eggshells” out of genuine fear of being singled out or in extreme cases bullied, yet the person at the center of these behaviors would be perfectly comfortable disregarding well-established institutional protocols and procedures. Well, I can tell you – no matter how good, schooling alone is not going to prepare you for this!
After many years of experience, as well as many direct (and at times very frustrating) interactions with such “difficult individuals,” I feel much more comfortable setting firm boundaries, saying “no” without feeling guilty, and managing passive aggression with “firm kindness.” I also begin to appreciate the information I wish I paid more attention to when on my behavioral science rotations in medical school – various aspects of human personality on the function–dysfunction spectrum and the implications of deeply ingrained, common human behavioral patterns. Finally, I learned to differentiate between very granular – but critically important – nuances in meaning and behaviors associated with specific emotions and feelings (e.g., resentment, jealousy, envy, fear, rage, guilt, and sentimentalism). Prompt recognition of corresponding emotions and behaviors within people is critical to effective organizational governance. At times, one must realize that “conflict management” may be the permanent state of certain professional relationships. Confronting bullies may be difficult, but is critically important to stopping the abuse cycle. Accepting this, although not a perfect solution, will make things easier and will help set bilateral (or multilateral) expectations.
Perhaps, the most important fruits of my overall growth and experiential learning are the realizations that: (a) I need to stay faithful to my “true north” and not become unduly influenced by manipulative individuals; (b) In my quest to help others, I must not neglect myself nor those who would be directly or indirectly affected by any changes resulting from even the most trivial decisions; (c) People will tend to see things from their own perspective and will likely fail to achieve the highest levels of empathy, even if well intentioned; (d) Institutions behave like autonomous “logic circuits” with various policies and procedures, which means that what makes sense to the institution may not necessarily make sense to you; (e) Even the best of people are capable of nonconstructive behaviors when stimulated to do so by their environment or others' behaviors; (f) Whenever options “A” and “B” are not to my liking, I either need to be at peace with one or the other, or I must push for option “C,” which takes a lot of energy but can be very liberating and satisfying; (g) I must do “what is right,” even if this means that “I might lose” – eventually those who consistently do “what is right” emerge as true leaders while those who go for the “quick win” are discovered and usually manage to discredit themselves (yes – they are perfectly capable of self-destructing, without any external help); and (h) Sometimes, I am the “bad person” – I need to be able to realize this, “own” my behaviors and consequences thereof, and gradually change myself through metacognition (or “thinking about how I think”) and deliberate practice.
I hope my humble recollections above will help guide the development of those who are in their medical/professional training and look forward to a career in leadership. These types of experiences will probably continue to be learned mostly at the personal level and will likely not become incorporated into formal educational curricula. In no way do I claim that these bits of advice are either unique or comprehensive, but I do believe they do represent an important “blind spot” that can only be addressed through excellent mentorship, well-intended coaching, and one's willingness to follow Benjamin Franklin's favorite quote, “Wise Men learn by other's harms; Fools by their own.”
| Pearl #9: Medicolegal Aspects of Clinical Practice|| |
There is an acute need for better medical malpractice training as the stress associated with a malpractice lawsuit can be very taxing on the health-care provider involved. In discussion with many colleagues across various specialties of medicine, the stress can be equivalent to a loved one's death or the process of divorce. Yet, medical schools and residency training programs rarely prepare future physicians for this highly likely scenario. According to the medical literature, by the age of 65 years, 75%–99% of physicians (categorized from low-risk to high-risk fields) will have been sued at least once. This can be especially devastating for physicians as we have a truly difficult time separating ourselves from our work. Generally, the process of a lawsuit takes approximately 5 years, and since one is not allowed to discuss details of the case freely, one may experience highly uncomfortable feelings of isolation and self-doubt during attorney communication and suit progression. Having been sued and having counseled numerous trainees and colleagues, this panelist can speak from experience. Some vivid memories include hand-holding of crying trainees (who were subsequently monitored for symptoms of depression and suicidality) to watching accomplished physicians leave medicine all together.
The fundamental question then arises: how do we define the stress associated with malpractice lawsuit so we can better develop a resilience strategy to help physicians manage it? Litigation stress describes the traumatic experience that physicians go through while or after being sued for alleged malpractice. Medical malpractice stress syndrome is when litigation stress leads to untoward changes in one's personal and professional life.,, The psychological impact on the physician (and family members) crosses many realms from shock and grief (i.e., denial, anger, bargaining, and guilt); to negative self-actualization (i.e., shame, victimization, outrage, and frustration); to somatic complaints (i.e., fatigue, gastrointestinal upset, chest pain, decreased concentration, and insomnia); to posttraumatic stress disorder (i.e., hypervigilance, reliving the experience, and avoidance); and to depression with a serious risk for suicide.,
The most common ways physicians end up in lawsuits include (a) having a large volume of patients with insufficient evaluation time; (b) working in a litigious geographic location; (c) managing numerous acutely ill patients that are likely to have unfavorable clinical outcomes regardless of the care provided; and (d) telling a patient that care from another physician was not optimal. The latter manner can be thought of as “self-inflicted” malpractice, and we must reconsider our competitive physician egos and stop participating in field tribalism. Sadly, the impact of lawsuits leads some physicians to perceive and practice medicine in a negative light (i.e., viewing patients as the enemy, ordering more tests, and practicing more conservatively in ways that do not benefit patients). Furthermore, physicians develop negative self-image, which in turn can lead to more errors and be associated with burnout.,,
So what can be done?First, we should begin by training medical students and residents in malpractice education. This can come in many forms including lectures, interactive simulations (i.e., mock depositions/trials), and participation on school/hospital committees. We should ensure that patient-centered care is performed in a kind and validating manner where it is acceptable to disclose errors in an environment that supports a “just culture,” and where the institution works on correcting systems issues in tandem with physicians., One must remember that when mistakes happen, most patients want to understand what went wrong, feel accountability from their provider, and feel that the error could help improve a system so that future patients may benefit. Hospital leadership should create peer coaching support that is specific to litigation education and stress. This support should come from experienced physicians and legal counsel who have been through the process and can provide counseling and wellness resources. At a national level, being involved with professional societies and advocating for governmental malpractice reform is of great importance.
Litigation stress does not have to destroy what we have all worked so hard to achieve. Understanding that we are not alone and that the process is more about assigning fault or money (via an attorney-constructed narrative) can be helpful in obtaining acceptance. Some of the relatively recent constructive developments in this area include the concept of “medical adversity insurance” or a no-fault approach to medical malpractice and quality assurance., Finally, we must always return to, and cherish, the truly wonderful aspects of being a physician. This includes the incredible connections we have with our patients who have the utmost respect and gratitude of having us in their lives.
| Pearl #10: Healthy Balance in Life|| |
I used to sit in lectures, staring at the inspirational posters that every classroom in the United States seems to have on its walls. I know you've seen them: folded mountains with someone standing on top, arms raised in a “V,” weather encroaching, dangerous but beautiful. “Follow your dreams.” “The sky is the limit.” Messages of attitude and motivation, all of them with an explicit message, but also an implicit one: “I am glad to be here.” “I am fortunate to be here.” “It took hard work to be here.” “It was worth the work.” “I chose this.” A simple message for a simple idea – motivation is the root of success, particularly in the face of obstacles.
For us in medicine, we know about motivation and we know about hard work. Probably during the course of medical education, no one needs to hang up that poster, because we've walked that path. We're headed somewhere, and our eyes are on that summit. I have often marveled that I have never seen an inspirational poster of a traumatic arrest resuscitation because, although different than those mountain pictures, it is no less true: I am glad to be here. I am fortunate to be here. It took hard work to be here. It was worth the work. I chose it. It is dangerous and beautiful.
What no one tells you is that there is no true summit, yet nearly everyone feels during their training like there is, or at least like there should be. You work hard in high school (staring at the mountain posters the whole time) to go to a good college with a good premed program, or to get you a spot in a combined program. You feel like you're there when you get your acceptance letter. But then, you're not done. You work hard in college. You don't go out with your friends, you stop playing an instrument and stop going to the gym, and you kill mice in a laboratory to build your CV even if you hate it. You feel like “you're there” when you get into medical school. But then, you're not done. You go to medical school, and you don't date. You have study groups. You don't cook. You eat dried food from a box. You give up your remaining hobbies. You accumulate debt, hundreds of thousands of dollars. You sleep on a mattress on a floor, turn off the heat, sacrifice. You are proud of your sacrifice. Your friends from high school marry and have families, have jobs and homes, and you stay on your path to your summit. You feel like you're there when you get into residency. But you're not done. Then, fellowship. But you're not done. You defer your life. Your life starts after medical school. It starts after 3–5 years of residency. It starts after 1–3 years of fellowship. But then, you want to work really hard, make a pile of money, and pay off your loans, just for a few years. Then you want to advance. You want to go from instructor to assistant to associate to full professor. Then you want to be director. Then you want an exit plan. What you want becomes exclusively what you aren't, and you define everything about your success and happiness in terms of what you hope to eventually achieve but never in terms of what and where you actually are. Eventually, you'll get there. But you're not done.
I am heavily involved in medical education, and I am saddened by the number of disillusioned graduates who tell me “I just feel like there should be something else. I did all this work to get here. I feel like there should be something else.” My message is to forget the summit. Stop thinking about the finish line. When you spend so much time on a path, you forget to look up from it and look around at everything else. You're looking forward to your life finally starting, but the truth is, it's already here. You're living it. Live it well. Take care of it. Protect your relationships. Love your family. Promote your “hobbies” to a status that allows for them to be the lifeline from burnout that they are. Take care of your body, as the greatest instrument you will ever have. Enjoy your education and work hard, but view it as the journey instead of the obstacle. Remind yourself that you are glad to be here. You are fortunate to be here. It took hard work to be here. It was worth the work. You chose this. But stop looking down the road and feeling like you're not done: Be here now.
| Pearl #11: from Friends to Patients – It's All About Caring, It's All About People|| |
The further along I get in my medical career, I am realizing more and more how important it is to have trusted friends and colleagues outside of work and especially outside of medicine. Many of us in our younger years, before getting consumed by the never-ending demands of a medical career, had friends and relationships. Once we entered into medical school and even more so as we move on to training, it becomes very difficult to maintain those relationships – many of them are lost over time as a result of our work-related demands. However, it cannot be emphasized enough how important these nonmedical relationships are to preserve and cherish. Throughout our medical education and career, it becomes easy to surround ourselves with friends and colleagues within the health-care system. Such work-related relationships often evolve from mutual interests – be it professional partners, colleagues with shared work frustrations, or even just people you meet and become friendly with merely as a function of how much time we spend at work. However, having at least one trusted friend outside of work is critical for so many reasons. Such an individual (or, if you are lucky, several individuals – but not too many) can help keep you grounded in reality. During those times in which you wake up in the morning and the first thing in your mind is the days (or hours) until retirement, such an individual can help remind you of the amazing work that you do in which the fundamental purpose – or why many of us went into medicine to begin with – is to make people feel better while prolonging the quality and quantity of their lives. In addition, on the other side of the coin, such an individual can serve as an excellent resource for maintaining perspective that a career in medicine is often just that – a career or a job. They can help offer valuable insights and perspectives when dealing with complex work issues, such as conflict management and resolution, contract negotiations, and even the decision to change jobs and relocate. They can be objective and honest, often to a fault, because, hopefully by definition, as your trusted friend, they are not influenced by so many of the inherent biases, agendas, and conflicts of interest that complicate professional career decision-making. If nothing else, such an individual can help keep you grounded in a reality that is often clouded by the complex and challenging world that being a physician entails.
Somewhat different from a close family member, who will love and support you unconditionally, such a friend can sometimes provide an objective and brutally honest voice in telling you those things that, while you may not want to hear, need to be told. After all, as they say – “that's what friends are for.” Over the years, their advice and insights – as someone looking from the outside in – can be invaluable, and as you evolve in your career and the nonpatient care, decisions become more difficult. Without a doubt, make sure that nonmedical friendships are maintained and cherished.
Another basic word of advice that cannot be said enough is, whenever in doubt – go and see the patient. While it may sound like a cliché that gets told to interns so that their chiefs and attendings can sleep at night – it is clearly a principle that holds true throughout your entire career. No matter what the decision-making or clinical outcome of a sick patient in the hospital, no one will fault you for making a bedside visit (and don't forget to document that visit!). When dealing with acutely ill, very sick patients, there will always be criticism for “not seeing the patient,” and decisions made at the foot of the bed will always trump those made over the phone. Patients will appreciate it, your colleagues and nursing staff will appreciate it, and your conscience will appreciate it. More often than not, the clinical outcome will not change; however, over the course of your career, many a complication or bad outcome will be averted by one last visit to look at a sick patient before you go to bed. Your patients may do better and you will sleep better.
| Summation|| |
It is important to remember that the above pearls of wisdom by no means represent an exhaustive list of “blinds spots” in our current UME/GME curricula. Moreover, in no way do the authors claim this list to be authoritative. Rather, our purpose was to stimulate discourse on concepts that are “important enough to matter” but perhaps not yet identified as “important enough to teach”. There are numerous other topics and issues that need to be mentioned, but are simply too extensive to include in this brief Editorial. To provide the reader with an overview of subject areas not specifically mentioned herein, but very important to the current discussion, we recommend that the below-referenced sources are consulted. More specifically, we would like for our audience to consider further reading in the areas of substance abuse recognition and management,, work-life balance/integration,, financial management/planning, burnout and mental illness,,,, career advancement including advanced degrees and certifications,, as well as the importance of developing and fostering empathy, compassion, flexibility, and life-long learning and improvement in both personal and professional pursuits., We hope that the reader will benefit from the above knowledge and experiences, and that indeed further discourse regarding our UME and GME curricula will be stimulated by this humble input.
| References|| |
Saeed M, Swaroop M, Ackerman D, Tarone D, Rowbotham J, Stawicki SP. Fact versus conjecture: Exploring levels of evidence in the context of patient safety and care quality. In: Vignettes in Patient Safety. Vol. 3. London, England: IntechOpen; 2018.
Sobel RK. MSL-medicine as a second language. N Engl J Med 2005;352:1945.
Smith R. Thoughts for new medical students at a new medical school. BMJ 2003;327:1430-3.
Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: General principles. Medical Teach 2019;2:1-9.
Covell DG, Uman GC, Manning PR. Information needs in office practice: Are they being met? Ann Intern Med 1985;103:596-9.
Gorman PN. Information needs of physicians. J Am Soc Infor Sci 1995;46:729-36.
Lee JM, Botteman MF, Xanthakos N, Nicklasson L. Needlestick injuries in the United States: Epidemiologic, economic, and quality of life issues. AAOHN J 2005;53:117-33.
Grossman MD, Stawicki SP. The impact of human immunodeficiency virus (HIV) on outcome and practice in trauma: Past, present and future. Injury 2006;37:1117-24.
Zhang MX, Yu Y. A study of the psychological impact of sharps injuries on health care workers in China. Am J Infect Control 2013;41:186-7.
Wilburn SQ, Eijkemans G. Preventing needlestick injuries among healthcare workers: A WHO-ICN collaboration. Int J Occup Environ Health 2004;10:451-6.
Dunn MM. Job negotiation. Am J Surg 2010;200:558-61.
Pargendler M. The role of the state in contract law: The common-civil law divide. Yale J Int Law 2018;43:143.
Pargendler M. Comparative contract law and development: The missing link. Geo Wash Law Rev 2017;85:1717.
Goleman D. Emotional Intelligence. New York: Bantam Books; 1995.
Goleman D. What Makes a Leader? (Harvard Business Review Classics). Brighton, Massachusetts: Harvard Business Press; 2017.
Goleman D, Boyatzis RE, McKee A. Primal Leadership: Unleashing the Power of Emotional Intelligence. Brighton, Massachusetts: Harvard Business Press; 2013.
Frisina ME, Frisina RW. Leading from your upper brain™. Int J Acad Med 2018;4:249. [Full text]
Uchino R, Yanagawa F, Weigand B, Orlando JP, Tachovsky TJ, Dave KA, et al
. Focus on emotional intelligence in medical education: From problem awareness to system-based solutions. Int J Acad Med 2015;1:9. [Full text]
Franklin B. Poor Richard's Almanack. New York, New York: Barnes and Noble Publishing; 2004.
Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med 2011;365:629-36.
Jones JW, Barge BN, Steffy BD, Fay LM, Kunz LK, Wuebker LJ. Stress and medical malpractice: Organizational risk assessment and intervention. JAppl Psychol 1988;73:727.
Charles SC. Coping with a medical malpractice suit. Western J Med 2001;174:55.
Dippolito A, Braslow BM, Lombardo G, Hoddinott KM, Nace G, Stawicki SP. How David beat Goliath: History of physicians fighting frivolous lawsuits. OPUS 12 Scientist 2008;12:1-8.
Ryll NA. Living through litigation: Malpractice stress syndrome. JRadiol Nurs 2015;34:35-8.
Lazarus A. Traumatized by practice: PTSD in physicians. JMed Pract Manage 2014;30:131.
Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al
. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005;293:2609-17.
Chen KY, Yang CM, Lien CH, Chiou HY, Lin MR, Chang HR, et al
. Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci 2013;10:1471.
Balch CM, Oreskovich MR, Dyrbye LN, Colaiano JM, Satele DV, Sloan JA, et al
. Personal consequences of malpractice lawsuits on American surgeons. JAm Coll Surg 2011;213:657-67.
DeCaporale-Ryan L, Sakran JV, Grant SB, Alseidi A, Rosenberg T, Goldberg RF, et al
. The undiagnosed pandemic: Burnout and depression within the surgical community. Curr Probl Surg 2017;54:453-502.
Stawicki SP, Firstenberg MS. Introductory chapter: The decades long quest continues toward better, safer healthcare systems. In: Vignettes in Patient Safety. Vol. 1. London, England: IntechOpen; 2017.
Tolentino JC, Martins N, Sweeney J, Marchionni C, Valenza P, McGinely TC, et al
. Introductory chapter: Developing patient safety champions. In: Vignettes in Patient Safety. Vol. 2. London, England: IntechOpen; 2018.
Havighurst CC, Tancredi LR.”Medical adversity insurance”: A no-fault approach to medical malpractice and quality assurance. Milbank Mem Fund Q Health Soc 1973;51:125-68.
Horwitz J, Brennan TA. No-fault compensation for medical injury: A case study. Health Aff (Millwood) 1995;14:164-79.
Hughes PH, Brandenburg N, Baldwin DC, Storr CL, Williams KM, Anthony JC, et al
. Prevalence of substance use among US physicians. JAMA. 1992;267:2333-2339.
Booth JV, Grossman D, Moore J, Lineberger C, Reynolds JD, Reves JG, et al
. Substance abuse among physicians: A survey of academic anesthesiology programs. Anesthesia and Analgesia. 2002;95:1024-1030.
Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al
. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine. 2012;172:1377-85.
Lewis S, Cooper CL. Work-life integration: Case studies of organisational change. John Wiley & Sons; 2005 May 5.
Spickard Jr A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. Jama. 2002;288(12):1447-50.
Tolentino JC, Guo WA, Ricca RL, Vazquez D, Martins N, Sweeney J, et al
. What's new in academic medicine: Can we effectively address the burnout epidemic in healthcare?. International Journal of Academic Medicine. 2017;3(3):1.
Duffy JC, Litin EM. Psychiatric morbidity of physicians. JAMA. 1964;189(13):989-92.
Turner AD, Stawicki SP, Guo WA. Competitive advantage of MBA for physician executives: A systematic literature review. World journal of surgery. 2018;42(6):1655-65.
Stawicki SP, Firstenberg MS. Fundamentals of Leadership for Healthcare Professionals, Volume 1. Hauppage, New York: NOVA Science Publishers. 2018.
Duffy FD, Holmboe ES. Self-assessment in lifelong learning and improving performance in practice: physician know thyself. Jama. 2006;296(9):1137-9.
Carmel S, Glick SM. Compassionate-empathic physicians: personality traits and social-organizational factors that enhance or inhibit this behavior pattern. Social science and medicine. 1996;43(8):1253-61.