Advice to the New Doctors About to take up the Responsibilities of Caring for Real Patients

480112_377789972350668_1587217215_nI was going to continue with my concerns and abjections to the new health care plan that the GOP has so hastily put together. However, yesterday, the first day of July is an important time in the history of a physician’s life. It is the first day that they really become physicians as a “real doc”, the Intern, with all the responsibilities of caring for their patients. I listened to one of the morning news shows where they were showing how the physicians in training were working such long hours and that it could result in errors due to exhaustion. I do understand the exhaustion having completed and Internship, a Residency in Surgery and a Fellowship in Reconstructive Surgery.                                                                                                                  I remember when I was in my fellowship at a famous University training program. I had a group of very smart student “doctors” on my service as we were making rounds. Making rounds is where we see each patient, either in the morning or evening, review their progress or lack of progress and review and adjust their treatment plans. The sickest patients were discussed in detail as to how to manage them during the evening and night hours. We were discussing a diabetic patient with a severe infection that we surgeons had to get involved to assist in the treatment of the infected abdomen.                                                                                         All of a sudden two of the students announced that they were leaving since it was now 5 o’clock and they didn’t need to stay after 5 o’clock. I was amazed and discuss the issues of continuity of care, seeing the patient trough complete treatment, etc. I explained that many times the most critical time of patient care is in the evening and that they all needed to be ready to treat patients even in the most critical time of their hospitalization.                                                                                                                They looked at me and told me that they could discuss the patients that is, the evening, and the night care on morning rounds the next morning. Many times when this happened in my years of teaching of the future docs, I tried to incentivize the student docs using their responsibilities and the joy of caring and curing disease, etc.     Yes, there were many long days, nights and sometimes it involved 2-3 days and nights in row, as I had to cover or work for my teammates who were sick or whose wife was in labor. Tiring, you bet, but you learned your limitations and who of the nursing staff to trust and the exhaustion built up, even using the senior staff if needed.                                                                                                                                       Sound horrible, yes, but that could be the real world if a patient or many patients are wheeled in to the Emergency room during notional or community disaster. When they call you needed all hands on deck what are you to do? Say sorry but you need more sleep and that you had a difficult day???                                                                                              The hours have been debated many times. Recently, despite concerns from the public about safety, the private group that oversees physician training voted to allow young doctors to work shifts as long as 28 hours.                                                                                 The new rules, which begin on July 1, relax work restrictions put in place in 2011, when mounting evidence showed that exhausted residents — the term for doctors in training — were endangering both patients and themselves. Currently, first-year residents are restricted to 16-hour shifts.                                                                                                     Leaders of the Accreditation Council for Graduate Medical Education said the work limits for first-year residents, known as interns, needed to be extended to match the 28-hour shifts now allowed for more experienced trainees. They said it was harming interns’ education by reducing their time in the hospital.                                                            Surgeons had been especially critical of the 16-hour limits, saying that at times interns were forced to leave the surgical team during an operation to avoid breaking the rules.                                                                                                                                     Public Citizen, the national consumer group that had been working with concerned physicians to try to defeat the proposal, called the change “reckless”. “As a medical resident, I’ve seen firsthand how exhausted and accident-prone my colleagues are during extremely long shifts,” said Eve Kellner, president of the Committee of Interns and Residents at the Service Employees International Union. “As a patient, I fear putting my life into the hands of a first-year resident physician who has been awake for 28 hours or longer.”                                                                                                                                           All doctors in training will still be limited to working 80-hour workweeks, averaged over four weeks. Studies have found that sleep deprivation is comparable to alcohol in its ability to impair performance. In one study, interns working in the intensive care unit for 24 hours or longer made 36% more serious medical errors than those working shorter shifts. The extended shifts also expose residents to a higher risk of car accidents as they drive home from work.                                                                                              Decades ago, there were few limits on how long doctors in training could work. But the death of 18-year-old Libby Zion in a New York City hospital in 1984 raised questions about the system. Zion’s father learned that his daughter’s primary doctors had been two residents who were caring for dozens of patients with little supervision.                                                                                                                            Because of the risks, the council adopted limits on resident hours in 2003, and further restricted the hours for interns in 2011.But the caps have been costly to hospitals, which have hired more staff to do work once performed by the physician trainees. Medicare pays the teaching hospitals as much as $130,000 or more a year for each resident, although the trainees get little more than half of that as salary. The council’s 35-member board, which voted on the proposal at the end of last month, includes four hospital executives. The group said Friday that it would not release details of the vote. The council had earlier accepted comments from the public on the proposal, but refused to release those comments. Public Citizen commissioned a survey of 500 Americans and found that 86% said they wanted to keep the 16-hour limit for first-year residents in place. And 80% of those people wanted similar 16-hour limits for the more experienced residents.                                                                                                                                              So, here are my recommendations for the new docs out there. Tracey Delaplain a physician suggested to her son a new surgeon that it is too easy to lose your way as a physician when faced with the daily stress of real medicine. “Spending time with the next generation of physicians gives me faith that we will always have a few doctors who stand out as not just competent, but caring healers. “My son is currently a surgical resident. A resident’s life is far from the glamorous stylized Grey’s Anatomy experience. It’s grueling and exhausting. I struggle as I watch him endure his chosen path. As a physician, I know exactly how he feels, and I know that he will survive. As a mother, I want to smother him with love, make him sleep more and fix his schedule so that he can have two days off in a row to come home for Christmas. My husband reminds me when I hang up the phone in tears, “Keep the faith. He will be fine. You did it too, and you survived.” “I know in my heart that he will not only survive residency training, but he will thrive. I envy you. I will never again feel the tumult and rush of surgical training. I’ll never feel the uncertainty of the first cut into human flesh, the adrenaline surge of a catastrophic bleed, the sickening grit of a malignancy in my hands, or the joy of knowing that in the moment my hands are the solution.”                                                                                                                                              “I envy your hands. I willingly retired my scalpel so passing the scalpel to you should be worthy of celebration and yet I feel grief. Ridiculous as it sounds, I envy your bone weary exhaustion; the exhaustion of endless learning and overwhelming uncertainty. I miss the burden of never knowing enough and the physical pain of sleep deprivation. These are the realities of post-graduate education that I will never feel again. To say that I lament those days sounds absurd, even to me, but that angst is in a physician’s DNA. We wouldn’t be who we are without its influence.”                                                                    “Take my scalpel, you’ve earned it, but you have still much to learn. You have been given the chance to cut so make every cut a chance to cure. I will expect nothing short of excellence in the operating room from you but the time spent in the operating theater is only a fraction of the time that you will give to your patients. The best surgeons know when not to operate. Be exceptional out of the operating room.”                                                                                                                                           “Draw strength and knowledge from your life’s lessons outside of the OR. I am a surgeon, and your father is an exceptional helmsman. You are both. By his example, your father taught you how to be a great captain. You learned to set the course and inform your crew of the plan before you set sail, much as you will do during your pre-surgery timeouts. He has shown you that everyone on his boat is important, and he always gives clear instructions when he needs their assistance. As the captain, you learned to acknowledge all safety concerns expressed by your crew with a thank you, even if you had already seen the potential collision and adjusted your sails well in advance. The surgeon like the helmsman can’t see around every corner and has to rely on his crew to be alert and secure in the knowledge that they can voice their concerns to him at all times. I hope you teach those around you the importance of teamwork and courtesy on a safe journey. The surgeon takes the ultimate responsibility for the safety of his crew and the human vessel entrusted to his hands.”                                                                                                                 “The helmsman can not control the wind or the tides, but he can adjust his course. You, the surgeon, can’t change the circumstances that bring a patient to you. Your choice to serve or to set sail will have been made long before the crisis. When a patient enters the trauma bay or your office, there’s no reason to spend any energy wishing it wasn’t so. What good ever came from shouting at the rain?”                                                                 “You will curse more than once when your trauma pager goes off for the twentieth time in as many hours. You will feel real anger when your patient is drunk, high, foul-mouthed, careless or ungrateful. You will wish that the patient had made better decisions, hadn’t waited so long to seek care or better yet that another surgeon was on call instead of you. Regardless of your feelings at the moment, take a deep breath and do your job. When you are truly at the moment, you will find exactly what you need to carry on and all of the should haves and could haves will no longer matter.”

“You can reef your mainsail or heave to and slow the forward progression of your vessel, but you can’t get off the boat in a storm. I hope you find the gift and perhaps the quiet divine guidance that allows you to realize that at the moment, you are the only one who can help the patient. At the darkest moments, adjust your course and engage the patient by saying, “I’m here to help.” There is no judgment in, “I will help you.” It will bring you and the patient into the moment where you can work together. Listen to the patient. What do they fear? What do they expect after surgery? Can you take the yoke from them and carry their fear for them? Can you align their expectations with the reality? Even unconscious trauma patient needs to hear that you care and that you are there for them. Believe me; you will forget the surgery and eventually the patient too. The patient will never forget you or their surgery.”

“Allow yourself to feel uncertain. You will never know everything. You will feel less certain and occasionally fearful in uncharted waters. Is the injury beyond repair, will the bleeding never stop, will the Mets win again? Learn to say, “I’m sorry. I’m sorry you are in pain. I’m sorry you are dying. I’m sorry I couldn’t do more.” Forgive yourself for being imperfect because you will make many mistakes. It is arrogant to believe that you can save every patient, so learn to say goodbye and when appropriate just get out of the way. It helps me to believe that there is a higher power to assist every patient at the end of his or her journey.”

“Learn to hesitate occasionally. Surgery is not always the best course of treatment. “Do you need to change course, adjust your sail, or rethink the surgical plan? Don’t be afraid to question the dogma of surgical certainty; question the technique, the equipment, the motivation, and the efficacy of the old and the new.”

“You have been given the power and burden of the scalpel. Wield it with wisdom. Stay centered and focused. I once wrote to you, “All first-year students start out as a shiny piece of new glass, none of us knowing what will be left of us at the end of our training. I wonder if you will become a weathered, beautiful piece of sea glass or will nothing, but sand remains of the original glass that is you.” You have kept your clear center despite the torrent of medical education so don’t let your surgical training take that away from you. Stay true to your ideals and teach your colleagues how to be exceptional helmsmen. Be an outstanding mentor and pass on the scalpel when the time comes with envy and pride.”

And those Doctors who have just finished their residency or fellowship and are about to start their careers, they will find a whole new world out there as they face a changing and tumultuous healthcare environment. The basis of their compensation, the size of the organization you join and even their role within that organization are changing, especially in today’s tumultuous health care and political environment. The move from compensation based on the number of procedures to the quality of outcomes makes healthcare organizations hungry for physicians willing to improve healthcare and embrace change as laid out in a report from the American Hospital Association’s HealthCareerCenter.com.

One major decision for new doctors is whether to work at a hospital or join a private practice, the report noted. About 57 percent of physicians work in practices owned by physicians, while hospitals or practices partially owned by hospitals employ nearly a third of doctors–a percentage that is growing. However, as of 2014, doctors in each group earned the same amount.

Here’s some of the conclusions from the report:

  • New doctors are more likely to work within a larger organization, as the number of small, independent physician practices keeps shrinking.
  • The ability to work as part of a team is a valued skill. With the shift to value-based care, the healthcare environment demands teamwork, as doctors rely on a group of varied practitioners to treat and care for patients.
  • Along with clinical skills, new doctors will require ‘soft’ skills, such as adaptability, empathy, creativity and leadership. Physician leadership will help determine the culture of healthcare organizations.
  • There’s a number of new roles available to physicians, including physician adviser, transitional care provider, chief experience officer and concierge medicine practitioner.
  • The most in-demand medical specialties include family medicine physicians and general internists.
  • The state where it’s easiest to fill physician positions is Ohio and the state where it’s hardest is New Mexico.
  • Be prepared to work long hours, but not as many as doctors averaged in the past. Physicians over 35 years old work an average of 49.5 hours a week. But only 36 percent work more than 50 hours a week, which is an eight percent drop between 2003 and 2013.

The report also includes a description of the hiring process that new doctors will undergo and compensation and incentive information.

Jordan Grumet, a physician, suggested that there are parts of medicine that are horrendous with moments too painful to recount and events that will break even the most innocent participants.                                                                                                          And then, there is unspeakable magic. I live for the days when a patient comes to the office with a particularly vexing set of symptoms. Specialist after specialist bows their head in disagreement. Laboratory values whisper falsehoods with jeering tongues. Symptoms are transient, physical exam signs inconsistent and in the midst of head scratching, an answer mysteriously appears. Maybe it is a common presentation of a rare cancer or a rare presentation of a common disease.   Explaining with words so fast that sentences jumble — ideas merge. The patient shakes their head enthusiastically less because of deep understanding, and more because they know that my excitement means that finally the answer will unfold like a blossoming flower selflessly bearing its pollen. I will eventually slow down enough to present a cogent explanation. And things will get better.                                                                                                                                                      It lifts me up when a patient sits down beside me after yet another life saving surgical procedure. When, at the end of the day, I have a spare moment to settle in for an intense conversation. I bite my tongue, become quiet and listen. I hear of hopes and dreams. I hear of pain and suffering, joy and fear. We talk like doctor and patient — like friends, like family members. We get past the intangibles of life and death and move on to the more palpable like dignity. Upon finishing, we leave the room in strength. We leave the room with resolve. We leave the room with tears in our eyes — all of us.                                                                                                                      And I love when an unwitting pattern is recalled from the deepest depths of memory. The clock is ticking. Heartbeats rise and fall rapidly. Knowledge accrued from past struggles presents itself at the most opportune time, and a life is saved. On the triumphant drive home from the hospital, with the radio blaring, I remember the patient who’s happy that such life-saving knowledge was attained. And I rejoice that all their suffering was not in vain, and neither was mine.

For all of the successful, busy and overwhelmed physicians you need to find a balance in your life. Alison DeNiro reviewed some suggestions that apply to all. The overworked tech CEO is now a cultural trope for a reason: Only 65% of tech workers said they were satisfied with their work-life balance, according to a recent survey from Comparably. This is a problem, as constant work and the resulting stress can lead to health problems such as impaired sleep, depression, diabetes, and heart disease—which not only hurt the employee, but also the company, in terms of turnover and rising health insurance costs.

Despite the pressure to be always on, finding the proper work/life balance is essential, experts say.

“It’s possible to be a tech leader and to make time for taking care of yourself,” said William C. Fisher, president of Quicksilver Software, Inc. ” But, it takes a willingness to make that a top priority and schedule the time.”

Here are seven tips from C-suite members in the tech industry on how they maintain a balance.

  1. Set email expectations

Follow France’s example and set limits for yourself and your staff in terms of when people should be available outside of work hours, said Mark Tuchscherer, president of Geeks Chicago. “In the tech world, the only way to truly achieve any kind of work/life balance is to disconnect,” Tuchscherer said. “We set and encourage times to not check email or projects. For example, after 5:30 or 6:00 pm, refrain from checking your work email, and don’t log into the VPN on weekends. “Jake Bennett, CTO of POP, said he sets the following expectations with his boss and colleagues about communicating after-hours: For something time sensitive, they can call his cell, but for anything else, they can send an email knowing he will answer in the morning.                                                                                                                                    “When people have to actually call you after-hours to contact you, they tend to more appropriately prioritize their ‘time-sensitive’ communication,” Bennett said. “And by keeping work email where it belongs—at work—it allows me to truly unwind at home.”                                                                                                                                             Gene Richardson, COO of Experts Exchange, said his philosophy is that work time is work time, personal time is personal time, and the two should not overlap, except in the case of an emergency. Employees in jobs that require them to be available in off-hours should be compensated appropriately, Richardson said.                                                                    “The most important thing I do everyday when I get home from work is to put my phone in the master bedroom and leave it there till the morning,” said Ryan Bartlett, CEO at SEO Direct. “I’ve seen a noticeable difference in my relationship with my wife and kids since I started doing this. I’m present, and my head is up, not down.”                                                 2. Allow for flexible schedules                                                                                                   This is a difficult one for physicians to utilize, but there may be some leaway. Flexible hours and work from home schedules give managers and team members the flexibility needed to more smoothly balance the intersection between work and life, said Suvas Vajracharya, founder and CEO of Lightning Bolt Solutions. His employees work from home two days per week, and are in the office three days per week. “It has proven to be a nice balance that offers flexibility and also reduced commute times, but we also benefit from our time together in the office—engaging with each other in-person allows us to maintain our office culture,” Vajracharya said.                                                                       Fred Schebetsa, co-founder and CEO of finder.com, says C-suite members should take advantage of the flexibility technology allows. “I think the idea of a traditional 9-5 or set blocks of time for work and play is antiquated and not conducive to productivity or creativity,” he said. “Thanks to technology, we can plug into work anywhere and at anytime which enables us to be more flexible. That means we don’t necessarily have to skip something personally important that might be on during the day, or wait until the next day to follow up if a great work idea strikes late at night.”                                                                                                                                                   3. Automate what you can                                                                                                         Tech leaders should seek to automate simple tasks to save time and energy, Bennett said. “Everything these days has an API or is scriptable, so I automate everything I can,” he said. “This starts with our development processes. Everything we deploy is automated, which means that hours of manual labor has been replaced with the click of a button.”                                                                                                                   Bennett also recommends employing automation at a micro level, using tools like Outlook rules to manage his inbox. “Companies should provide tools to their employees that help them maximize their work hours by automating the busy work associated with their jobs,” said Mike Puterbaugh, CMO of Ziflow. “Automation is clearly a hot topic right now, so it should be top of mind for managers to consider how to harness that to make their employees’ lives easier.”                                                                                                           4. Prioritize work and personal tasks equally                                                           GoDaddy’s Chief Product Officer Steven Aldrich recommends treating personal and professional tasks with equal levels of importance. “Block off time on your calendar for your daughter’s soccer game and treat it with the same preparation and sense of urgency as a team meeting,” he said.                                                                                                      Shawn Boyer, founder and CEO of DieHappy, also recommends putting personal plans into your calendar, just as you would work events. “When someone asks you to do a meeting or a call for work, you can legitimately just say to them, ‘Sorry, I already have another commitment then,'” he said. “For most of us, if it isn’t on the calendar, it isn’t going to happen.”                                                                                                                                 5. Exercise regularly                                                                                                               “When you need to think creatively or clear your head, get up and move,” said Aldrich. “A Stanford study showed that people generate 60% more creative ideas while walking.” Randy Wootton, CEO of Rocket Fuel, said that while true work/life balance is difficult for senior executives to achieve, his goal each day is to manage his energy to be fully present from morning until evening. Early morning exercise is one way to do this: “I wake up early each day to ride my bike or run before jumping into a day full of meetings,” Wootton said. “This time allows me to think about what I want to accomplish that day and to wrestle with problems and/or ideas for an extended period of time. I also find the energy boost I get from exercising first thing helps fuel me through my day.”                                                                                                    6. Take your vacation time                                                                                                         A recent poll conducted by NPR, the Robert Wood Johnson Foundation and Harvard University found that about half of Americans who work 50+ hours per week say they don’t take all or most of the vacation time they’ve earned. Among those who do take vacations, 30% said they do a significant amount of work while away. Mike Beach, CEO of marketing tech agency Cardwell Beach, called this phenomenon “vacation machismo,” and said that it’s based in the fear of falling behind in the competitive tech industry. “It’s unsustainable, it’s bad for our health, our creativity and our productivity, and yes, it’s ultimately detrimental to the bottom line,” Beach said. “So step one: take your damn vacation days, and support your team in doing so! When your work is your whole life, both suffers.” When you do go on vacation, try to go off the grid. “With technology what it is these days, it’s easier said than done, but if you’re trying to relax on vacation, lounging by the pool or sunning on the beach, try to pick a spot without Wi-Fi so you’re not tempted to work,” said Simon Slade, CEO and co-founder of SaleHoo.                                                                         7. Make ‘me time’                                                                                                                Protecting your “me time” is key for work/life balance, said Aldrich. “Block time on your calendar dedicated to relaxing, reading or exercise,” he said. “Spend a few hours doing something you enjoy. Feel comfortable turning down events or happy hour to focus on you at least once a week.”                                                                                                            Craig Malloy, CEO of Lifesize, agreed. “In addition to always attending my kid’s activities, I find time for activities I personally enjoy,” he said. “I played the piano in the past and have recently taken up lessons again. I find it is a relaxing way to take my mind away from work and use another part of my brain to focus on something creative.”                                                                                                                                         Part of making “me time” means having a strong support system in place, said Maria Merce Martin, CEO of Optime Consulting. “Being a business owner of a tech company and a dedicated mother and wife, I have learned that in order to do it all, we must stop trying to control it all,” she said. “Having the right support team I trust in business and personal life brings the added value needed for achieving goals.”

Enjoy your time in training, learn what you need to care for your patients and realize your limitations and call for help when you need it. Happy Fourth of July to All.

 

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