Summer Wellness Roundup!

By Brad Zehr, MS4 

Below is a curated set of items pertaining to wellness in medicine and medical training that I highly recommend as we savor the end of summertime. 

Morning report (“Becoming a Physician” series, NEJM, June 2017)
http://www.nejm.org.ezproxy.bu.edu/doi/full/10.1056/NEJMp1701939
Sonia Singh, MD, a general internist and primary care physician at Stanford Health, recounts her early-morning routine as a Medicine resident. Her essay beautifully captures the shared experience of being an overwhelmed and overworked medical trainee. In the daily crush of tasks that one must complete before 10 a.m. Morning Report, Singh extolls the value of deliberately stopping one's frantic mental checklist and internal ticking clock to be present with a patient every day, even at the expense of perfectly executing the task list.  

#pinksocks
http://pinksocks.life/about-us/
Pinksocks is a community of health care professionals striving for change in the culture of medicine. They advocate for greater emphasis on humanistic thinking and behavior among hospital teams, which starts with having more fun. The concept went viral when Nick Adkins, a digital health entrepreneur, wore pink socks at the HIMSS 2015 conference and Eric Topol Tweeted a pic of them to his nearly 100,000 followers. 

#CrazySocks4Docs
http://www.bmj.com.ezproxy.bu.edu/content/357/bmj.j2727.long
Yes, there is a 2nd relevant fun socks hashtag. Geoff Toogood, a cardiologist and physician mental health advocate in Melbourne, Australia, created the hashtag and designated June 1, 2017, as a day to advocate for physician wellbeing. Health care professionals across Australia (and a few from the U.S.) posted pics of their crazy socks to show solidarity, as did Australian Minister of Health Greg Hunt. Looking forward to June 1, 2018!

Characterizing the source of text in electronic health record progress notes (“Physician Work Environment and Well-Being” series, JAMA Internal Medicine, May 2017)
http://jamanetwork.com.ezproxy.bu.edu/journals/jamainternalmedicine/fullarticle/2629493
Many have cited the current generation of EHRs as one root cause of the growing physician/trainee burnout problem. Others have cited our current style of EHR note-writing as a root cause of medical errors that can potentially harm patients. In this innovative and important study, the authors analyzed 23,630 inpatient progress notes written by 460 hospitalists, residents, and med students in UCSF's Epic EHR from Jan-Aug 2016 by classifying characters in the notes as one of three possible types: 1) Fresh (manually entered), 2) Imported (smart phrase auto-populated), or 3) Copy-Pasted. On average, 18% of text was fresh. More systems science research is necessary to assess how we are actually practicing medicine on a daily basis and how we can leverage technology to improve physician satisfaction and protect patient safety. 

Association between indulgent descriptions and vegetable consumption: Twisted carrots and dynamite beets (JAMA Internal Medicine, June 2017) 
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2630753
Wellness incorporates both psychological and physical wellbeing, and nutrition is fundamental to both. This paper describes an experiment in a large cafeteria at Stanford University wherein the language used on veggie labels was the independent variable and amount of said veggies purchased was the dependent variable. Use of “indulgent descriptors” such as “sweet sizzlin' green beans and crispy shallots” increased the number of people selecting the veggie by 25% compared to basic descriptor (“green beans”) and by 41% compared to healthy-restrictive descriptor (“light 'n' low-carb green beans and shallots”). There was a similar effect on the amount of veggies taken per person. Any thoughts on an “indulgent descriptor” of exercise?

The hidden dying of doctors: What the humanities can teach medicine, and why we need medicine to learn it (Los Angeles Review of Books, May 2016)
https://lareviewofbooks.org/article/the-hidden-dying-of-doctors-what-the-humanities-can-teach-medicine-and-why-we-all-need-medicine-to-learn-it/
In her commentary on Paul Kalanithi’s “When Breath Becomes Air," Lois Leveen pauses at one particular passage in the book: the point where Kalanithi describes the suicide of his resident physician colleague, “Jeff." Leveen examines the power of art and literature to frame one’s personal struggles, just as Kalanithi used a simple 7-word Beckett passage to find meaning and purpose after his terminal cancer diagnosis. 

Do you have more recommendations? Send them to me so we can feature them in our next post. My email is brzehr@bu.edu.

 

Spring Wellness Roundup!

By Brad Zehr, MS4
brzehr@bu.edu

Below is a hand-curated set of items pertaining to wellness in medicine and medical school that I highly recommend as we all transition into our next year of training. 

The Doctor Paradox (podcast)
http://thedoctorparadox.com

A 2015-16 podcast "about addressing why despite having incredibly meaningful jobs, doctors are increasingly unhappy in their work." The host is Dr. Paddy Barrett, an interventional cardiologist and digital medicine advocate who is a Clinician Scholar at the Scripps Translational Science Institute in San Diego. The series features more than 50 guest physicians whose careers vary widely but all share a common theme of tailoring their work to match their passions, including physician entrepreneurs, physician artists, and physician adventurers. Check it out, you'll feel better about your future. 

 

The Year of Hygge, the Danish obsession with getting cozy. (New Yorker, Dec 2016)
http://www.newyorker.com/culture/culture-desk/the-year-of-hygge-the-danish-obsession-with-getting-cozy

Hygge, pronounced "hoo-guh," is a state of being that we all recognize when we're in it: contentment, peace, gratitude, coziness, indulgence, relaxation, comfort and conviviality. Now hygge is having a cultural moment with dozens of books and websites devoted to exploring it. This article tells of its origin and its potential transatlantic applications. It's fun reading. 

 

Book Review: 'in-Training: Stories from Tomorrow's Physicians.' (Clinical Correlations, March 2017)
http://www.clinicalcorrelations.org/?p=9400

Amar Parikh, MD, a third-year internal medicine resident at NYU Langone Medical Center, reviews the recently published book of medical student essays on training, work, life, and patient care. The book features the best writing from in-Training, "the agora of the medical student community," and was published in partnership with the Arnold P. Gold Foundation. 

 

NEJM Interview: Dr. David Rosenthal on the effect of the electronic era on physician satisfaction. (Audio podcast, 7 minutes, New England Journal of Medicine, Nov 2016)
http://www.nejm.org/action/showMediaPlayer?doi=10.1056%2FNEJMp1609055&aid=NEJMp1609055_attach_1&area=&viewType=Popup&viewClass=Audio

A quick listen (especially on double speed, which I recommend for interview-based podcasts), about the modern EMR-centric workflow of physicians and trainees, and how it is likely a contributing factor to burnout and dissatisfaction. 

 

Kathryn (NEJM Perspective, March 2017)
http://www.nejm.org/doi/full/10.1056/NEJMp1615141

Dr. David Muller, the dean for medical education at the Icahn School of Medicine at Mount Sinai, shares his experience with losing a fourth-year medical student to suicide in August 2016 and how the ISMMS community responded. Dr. Muller believes a root cause of trainee burnout, depression, and suicide is "a culture of performance and achievement that for most of our students begins in middle school and relentlessly intensifies for the remainder of their adult lives." This editorial is very important reading. 

 

Biomedical researchers need better work-life balance to succeed and flourish (Op-ed, STAT News, April 2017)
https://www.statnews.com/2017/04/21/work-life-balance-biomedical-researchers/

Robert Lechler, MD, president of the Academy of Medical Sciences in the U.K., discusses a new campaign, #MedSciLife, to humanize medical scientists and encourage researchers to prioritize home life and side interests as part of a holistic approach to balancing career and life. Same goes for early career scientists and trainees. 

 

Do you have more recommendations? Send them to me so we can feature them in our next post.

Physician-author Samuel Shem speaks about ‘staying human’ in medicine

By Brad Zehr (BUSM 2018)
brzehr@bu.edu
2/19/17

When it was published in 1978, the satirical novel “The House of God” was met with “ridicule and derision” by medical school deans and prominent physicians. Thirty years later, its author delivered the prestigious “Humanism in Medicine” lecture at the 2008 meeting of the Association of American Medical Colleges.  

“The reason I write is to draw attention to and to resist injustice,” said Stephen Bergman, MD, D.Phil., the 2017 AOA Visiting Professor at BUSM. Dr. Bergman, now professor of medical humanities at NYU School of Medicine, is better known by his nom de plume, Samuel Shem. He spoke to a room packed with BUSM students, residents, and attendings Friday morning.

After experiencing a brutal and dehumanizing intern year at Beth Israel Hospital in Boston, Shem authored his best-known work – an irreverent send-up of the absurdities and irrationalities of medical training.

“The House of God” was rejected by most senior physicians at the time but gained a devoted following among subsequent generations of medical students and residents. The work is also recognized as a literary masterpiece and was recently named the No. 2 best satire of all time by Publishers Weekly. (No. 1 is “Don Quixote.”)

Shem’s talk at BUSM closely mirrored an article he wrote for The Atlantic in 2012. Below are several excerpts from that article that encapsulate Shem’s message.

I took this pseudonym because I was just starting my psychiatric practice and wanted to protect my patients from knowing that their therapist had written such an irreverent novel. (They all found out, and didn't care -- but "Shem" had arrived, and refused to depart.) I also felt that real writers had no place in going out and publicizing their novels. I refused all invitations. And then one day I got a letter forwarded from my publisher, which included the line:

"I'm on call in a V.A. Hospital in Tulsa, and if weren't for your book I'd kill myself."

I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey of speaking out, around the world, about resisting the inhumanity of medical training. The title of my talk is almost always the same: "Staying Human in Health Care."

The theme of my speaking out is simple: the danger of isolation, the healing power of good connection. And any good connection is mutual.

 … The novel can be read as a model of nonviolent resistance. Big hospitals, like all large hierarchies, are "power-over" systems. The pressure comes down on the ones at the bottom, and they become isolated. Not only do they get isolated from each other, but each gets isolated from his or her authentic experience of the system itself. You start to think "I'm crazy," instead of "This is crazy." In The House one of the interns does go crazy, and another commits suicide.

The crucial question is how to find mutuality -- or "power-with" -- in a "power-over" system. Historically, the only threat to the dominant group -- whether of race, gender, class, sexual preference, ethnicity -- is the quality of the connection among the subordinate group.

… At a point toward the end of the novel, the fraught protagonist has to make a choice. He struggles with it until he hears a kind of voice in his head:

"Don't spread more suffering around. Whatever you do, don't spread more suffering around."

This is the culmination my learning so far. All of us will suffer -- it's not optional. Some will suffer more, some less. The issue isn't suffering, it's how we walk through it, and how we help others walk through it. If we decide to walk through suffering alone -- "stand tall, draw a line in the sand, tough it out" -- we will suffer more, and spread more suffering around. 

This is where we health-care folks come in -- this is our job, to be with others in caring. 

----

If you are curious to learn more about Shem’s philosophy of writing as an act of resistance and humanism, I recommend his 2002 essay “Fiction as resistance” in the Annals of Internal Medicine.

Why I attended the 2016 International Conference on Physician Health, and what I learned

By Brad Zehr (BUSM '18), brzehr@bu.edu
Feb 8, 2017

Medicine is by nature a field in flux, but we are entering medicine during a period of historically intense disruption that can feel chaotic. 

The digital revolution, having radically transformed and improved so many facets of modern life, has been conspicuously tardy in hospitals and medical schools. Inelegant, inefficient electronic medical record systems abound, rote memorization of endless factoids remains dominant in medical education, and the use of mobile phones is actively discouraged throughout medical training despite the emergence of many potentially game-changing apps. 

Simultaneously, the speed of information and knowledge creation has accelerated to a degree that can feel unmanageable. The daily crush of patient data is dizzying. The burgeoning genomic revolution, "precision medicine" movement, and "Big Data" developments will further compound the information glut. Documentation requirements are expanding, while time allotment per patient is decreasing. 

National health care reform, meanwhile, is systemically disrupting the delivery of health care. New models of care, new incentives, and new rules often complicate the workflow of physicians. Byzantine requirements for reimbursement, conflict with insurance companies, and soul-crushing administrative tasks erode morale. And perpetual political conflict surrounding health care imbues the field with a sense of instability, uncertainty, and tension.

An editorial last December by Steven Adelman, MD, the director of Physician Health Services, Inc., and Harris A. Berman, MD, the dean of Tufts University School of Medicine, captured the zeitgeist in its title: "Why are doctors burned out? Our health care system is a complicated mess."

These major stressors on the health care system and disruptions in the practice of medicine exacerbate the inherent pressures of being a doctor -- avoiding any error that could harm a patient, witnessing human suffering and injustice, contemplating death and dying, prioritizing patient care over self-care, and balancing competing demands of the clinic, research, teaching, leadership, and advocacy, not to mention time for family, friends, and solitude. 

Traditional media and social media are saturated with stories about the epidemic of burnout among physicians and physician trainees, a phenomenon well documented in the academic literature. In fact, a new journal titled Burnout Research launched in 2014, and a 2015 JAMA editorial argued that depression among medical trainees had reached a "crisis level." Recognizing burnout as a worsening problem, the National Academy of Medicine recently announced a clinician wellbeing and resilience initiative

Given this worrisome atmosphere, and given my own personal experience of losing a friend and medical school mentor to suicide, I decided to attend the International Conference on Physician Health this past September in Boston. Al Nadjarian (BUSM '17), a steering leader of the BUSM Wellness Initiative, also attended.

(Moment of Zen / Fun Fact about Al and I: One time, for the sake of achieving comedy excellence at BUSM Skit Night 2014, Al took pictures of me walking around the South End in a cat head costume.)

Below is an outline of the key take-home points and resources I gathered from the conference.