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Submitted July 2020

Editors note:

Our guest writer this month is Dr. Anna Vu-Wallace. Anna is a Hospitalist, PWP Committee member and Director of the quarterly Stress Reduction Meditation Workshop for Healthcare Professionals. 

Brian

bsayers@austin.rr.com




Dear Friends,

Being in the hospital gives me a unique perspective on the current situation of the pandemic. Some of you shared with me that you don’t even look at the news anymore. That is understandable given the tumultuous period of our time. There are other ways to obtain vital information. This is a link to our statistics on COVID locally.

As hospital physicians, we are tasked with reaching everyone who may have influence as we see the sharp rise in our county and state. As I write you today, our hospitals are filling up. We are near capacity as we prepare our convention center for overflow.

Let me share with you what my typical day looks like. Shortly after awakening, I put on my scrubs and head out. Fear of taking this virus home and infecting my family takes hold as I don my N95 mask tightly to my face. Protective goggles are placed. Shoes from the day before left in the garage wait for me to put back on. As I enter the hospital, another mask is placed on me along with a shield. As I enter the COVID unit, I am covered with a gown and hair cover and 2 layers of gloves. My shoes are covered with shoe coverings. By the end of the first hour, my face and ears are painful due to the gear I must wear. The back of my ears bleed on occasion. By the time I get home, indentations mark how long I have been working. I strip off my contaminated clothes in the garage. I dare not to touch anything until I shower. Even then, I know how unpredictable this virus is. I pray my family will be ok as I have decided not to find different living arrangements isolating from them as there is no end in sight.

I attend to many. Without a definitive treatment for COVID, the sorrow of families of the dying is often overwhelming, relentless.

Today, I learned that at least 12 nurses I worked with have been infected and sick, 7 hospitalized. There have been at least 4 physicians infected. I know some will die. Our nurses are at the greatest risk. The longer we are exposed to COVID-19, the higher our chances of getting infected and sick despite PPEs. We are seeing such a steep climb in hospitalizations that Travis County becomes a topic of national news each night. What can I do? I can ask for your help. Would you make your own plea to your patients, friends, and family? These are some of the things we ask to help us control the spread of COVID-19:

-Would you wash your hands frequently, wear a mask outside of your home and physical distance for the next year?

-Would you not invite friends to come to your home for dinner/drinks until our local health departments clear to do so?

-Would you stay home when possible? We have a stay home order from Mayor Adler.

-Would you hold off on any church gatherings until we see a trend downwards for at least 2 weeks?

I know this is difficult. Community is vital to our very human journey. From my perspective, we are still in community, just in a different way. In our difficulties, there is an opportunity for growth. We can now see disparities in access to healthcare and what populations are at greatest risk. We can now see how our system is broken and can work for change.

Before sending this email, I explored my motivation. Yes, I don’t deny that I ask for me. However, I also believe I ask for all of us. What I have truly learned from this virus is how connected we all are. What we do individually will affect the collective.

In gratitude,

Anna Vu-Wallace, MD






Submitted June 2020

Wabi-Sabi



 

Like many of you, I’ve spent the last few months on a new and unpredictable schedule. Doing telemedicine from home (where I never seem to have quite what I need), then back to the office to see folks that need to be seen in person, semi-hypoxic from masking, with schedules, workstations, basic procedures all far from the routines and systems I’ve arranged in my office all these years. In medicine, if not life in general for some of us, there is an unspoken quest for perfection. Perfection that provides the kind of care for patients that we want for them, perfection that might isolate us from criticism, perfection that makes our days flow seamlessly. Of course, we know that imperfection and its twin, uncertainty, is actually what punctuates our days, and how we navigate that has much to do with our happiness. I’ve found that patients have generally been flexible and understanding about the new level of imperfection and inconvenience in medical care these days, certainly more so than me. Navigating those challenges has even formed a new kind of bond with some of my patients who have needed more help lately, and relaxing a bit and accepting imperfection and uncertainty might, perhaps, produce a new kind of wholeness described in this way by Rachel Remen:

 

“The marks life leaves on everything it touches transforms perfection into wholeness. Older, wiser cultures choose to claim this wholeness in the things that they create. In Japan, Zen gardeners purposefully leave a fat dandelion in the midst of the exquisite, ritually precise patterns of the meditation garden. In Iran, even the most skilled rug weavers include an intentional error, the “Persian Flaw,” in the magnificence of a Tabriz carpet. In Puritan America, master quilt makers deliberately left a drop of their own blood on every quilt they made; and Native Americans wove a broken bead, the “spirit bead,” into every beaded masterpiece. Nothing that has a soul is perfect. When life weaves a spirit bead into your very fabric, you may stumble upon a wholeness greater than you had dreamed possible before...”

 

In traditional Japanese culture, wabi-sabi is a world view centered on the acceptance of the transience and imperfections of life, the natural cycles of growth, decay and death, the beauty of nature, the frayed edges of existence. Derived from Buddhist teachings, it stresses simplicity, humility, intimacy, and appreciation of the natural world. Control, possessions, and predictability are notably absent. Our lives in the time of coronavirus, and beyond, are marked by existing in a magnificent but imperfect world in which we all live imperfect lives, creating a kind of kinship with all humanity. From impermanence and imperfection may come frustration, anxiety, and sadness, but also the possibility that we might find growth and acceptance, see the world through a different lens, even discover self-compassion, the very definitions of wisdom that comes to us only through living in harmony with the imperfections of life.

Brian Sayers, MD
Chair, TCMS Physician Wellness Program
bsayers@austin.rr.com



Submitted May 2020

Telemedicine and the Opening of Eyes 



 

Like many of you, a very short time ago I made the transition to telemedicine visits almost overnight, just as countless other changes went on within our small practice. While imperfect, telemedicine visits in the current environment offer a certain kind of safety that we just can’t pass up. I knew that there would be significant disadvantages, but I would soon learn that this strange new world of sitting in my study and suddenly finding myself inside of my patients’ homes might add an entirely new dimension to my relationship with them.

Even the simple platform that we use presents significant hurdles for many of our older patients, and our receptionist, now repurposed as our “IT Hostess,” sometimes spends more time getting them online and their mic and camera working than I do with the visit. The first week I’ll have to admit I was entirely distracted by the patients’ surroundings. Most use a laptop set below their face and I am often greeted with a perfect anatomic tour of their nostrils and popcorn ceiling. For those who position the camera at eye level, there is invariably a background nothing short of fascinating, even when entirely ordinary. On the wall behind them I have seen everything from 50 year old wedding pictures to an image of Jesus, family photos, and on memorable occasions a Grateful Dead concert poster, part of what I think was a framed rendering of “dogs playing poker,” and once, what appeared to be a varmint tail of some sort nailed to the wall. I’ve seen kitchens in the background with a concerning array of dirty dishes, but also palatial surroundings, breathtaking hill country or lake views and magnificent art. Occasionally, when the name of a certain medicine eludes them, I get a walking tour of their bathroom and medicine cabinet.

The initial fascination with my patients’ surroundings soon gave way to what it should have been for me all along: a sense of appreciation to see them in their natural surroundings, generously inviting me in. More often than not they are chatty, often much more interested in having some company in for a visit than telling me much about their medical issues. I have come to see that in these visits, if I take some time, I learn more about them and who they are than I have in 20 years or more of in-office visits. Invited into their homes, I have been given a seat on what to them is sacred ground, and with most I feel a new sense of kinship, and witness a certain vulnerability and hospitality that must have been what caused our predecessors to keep doing house calls with little complaint until not so long ago. On a good day, when I allow it, telemedicine visits help me to see my work and my patients through new eyes. Perhaps this is what physician wellness pioneer Rachel Remen had in mind when she penned these words:

“Often finding meaning is not about doing things differently; it is about seeing familiar things in new ways. When we find new eyes, the unsuspected blessing in work we have done for many years may take us completely by surprise. We can see life in many ways: with the eye, with the mind, with the intuition. But perhaps it is only by those who speak the language of meaning, who have remembered how to see with the heart, that life is ever known or served.”

Brian Sayers, MD
Chair, TCMS Physician Wellness Program
bsayers@austin.rr.com



Submitted April 17, 2020

The Upside of Uncertainty


 

There is not much in our lives that hasn’t changed drastically in the last three months. Each of us is experiencing fallout from the pandemic in our own unique way. Each of us is writing a story that will only be fully told months or years from now when we see these events with the perspective that only time can give--hopefully from a place of relative safety, a place where it may seem like we have all collectively exhaled. Our lives are not just drastically different at this time but will just as certainly never be the same, in ways that we are only now starting to see an outline of. There is great tragedy, danger, fear and anxiety all around us, a sudden uncertainty that is at once disturbing and disorienting. But just as surely, there is emerging an unexpected upside from this time of uncertainty.

This past week, I asked members of the Physician Wellness Program Steering Committee to write a few lines for me regarding strategies and observations they have to offer during this difficult time. By far the recurring theme was that this communal “time out” of sorts has, even with stress and tragedy around us, brought us closer together as families, helped us appreciate our friends and colleagues and our work, all of which we so often take for granted. It has caused most of us to pause some work activities, volunteer commitments, our children’s overextended schedules, the frenzied pace of our lives. While some of us are busier than ever dealing with the fallout of the pandemic, many find themselves on a reduced schedule, certainly at home more, and with other commitments lessened, time to think, to reassess priorities, schedules, friendships and family. Time to realize how much we assume, how little we reflect, how much we miss. Several observed that this time of uncertainty has bred a new sort of gratitude and compassion and feel that it may just give them a second chance to bring about positive changes in lifestyle and outlook.

More of the Committee’s observations and strategies for weathering the storm, along with notes about recently enhanced PWP programs on this video.






Physician Wellness Counseling

  • Featuring our outstanding psychologists
  • Remote/telemedicine visits
  • Psychiatry volunteers

The Physician Wellness Program offers anonymous, free sessions with TCMS vetted psychologists. So far, the program has funded over 500 confidential sessions with our therapists.

As an added benefit of the program, for the next three months, TCMS has a referral list of psychiatrists who have offered to participate in the program.  If you feel you would benefit from seeing a psychiatrist in addition to, or instead of, a psychologist, let us know when you call the helpline.

The program can be easily accessed, and privacy is strictly protected. A certified Gottman Couples Therapist is now available in addition to individual counselors to help with work, personal, or marital issues.

The cost of the first four sessions is covered by the program.

Whatever the issue, this program is your safe harbor. Nothing is reported, no diagnosis made, no insurance billed.

To access the program, call the wellness line at 512-467-5165 or visit the PWP counselor page.




Submitted March 20, 2020

 

Confidential, free counseling program for TCMS members and spouses now offering telemedicine/remote services.

 
 
Masks, gloves, raw hands, empty store shelves, telemedicine, nosediving stock market, the very real concerns for our loved ones and ourselves. Uncertainty. Chaos. Yet in the midst of it all, our TCMS members are doing amazing things for our community. But for some, it comes at a price.
  
For the past two years the PWP Counseling Program has been there offering convenient, anonymous, free counseling services by our vetted doctorate level therapists. Over 500 visits have been sponsored by the program to date.
  
To make things even more accessible in these stress filled times, all five of our therapists offer initial visits by phone and are now offering ongoing counseling via telemedicine in the privacy of your home, office or where ever you want to access it.
  
Take a minute to check out your medical society’s PWP program and our therapists’ bios. Call our anonymous Helpline 512-467-5165 for assistance, or contact one of our therapists directly . Just identify yourself as a TCMS member (or spouse) and they will take it from there.
  
Stay safe. Stay connected.
  
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
bsayers@austin.rr.com

 

 

Submitted March, 2020

Profiles in Courage

A recent story I read about Washington politics made reference to John Kennedy’s Pulitzer Prize winning book, Profiles in Courage. Kennedy wrote the book while still a senator, a book that looked at politicians who had, at their own personal or political peril, taken courageous moral stands that were counter to party or popular opinion. I spent some time with it, hoping to see a model that might help me recognize admirable courage in modern day Washington. There is a quote in the introduction that caught my eye. “To be courageous . . . is an opportunity that sooner or later is presented to us all . . . in whatever arena of life one may meet the challenge of courage . . . each man must look into his own soul.” I gave up considering where courage might or might not be in Washington as thoughts turned to who closer to home I’d consider courageous. I did not have to think for long.

For almost a decade, I’ve served on and chaired the TCMS Physician Health and Rehabilitation Committee. PHRC advocates and assists in monitoring our colleagues who are in recovery from alcohol or drugs, its goal being to help physicians in whatever ways we can to be successful in their recovery, to protect their license and livelihood, and to see them on a path to a new and fulfilling life. The committee is made up of physicians from all kinds of practice settings and specialties, including psychiatrists and addictionologists, active and retired, some in recovery, others simply interested in helping their colleagues. My own path was as an adult child of an alcoholic, a father who died of alcoholic liver disease at age 40 as the 12 year old version of me looked on, in an era when getting help was greatly stigmatized. For recovery to be successful takes great personal courage. It also takes the help of others.

In a recent interview, Elton John made reference to the importance of community, of asking others for help, in the process of recovery. “We were all people who had made bad choices and seen the consequences, but then made the same choices despite ourselves . . . again and again and again. The truth of it all was that simple: no matter where we had come from, what we had accomplished or failed to accomplish, what our life experiences had been up to that point, we were all the same. And none of us would get better without asking others for help.” And so it is that PHRC exists, to play at least a small role in helping those in recovery.

Our colleagues who go through our five-year monitoring program all have their own story, unique origins that brought them to us, but there is a common pattern. There is usually anger and denial early on. After an extended stay in rehab which most of them agree to and are successful with, they reemerge with less anger and denial, often replaced by a period of a sort of disequilibrium, even as they see the framework of a new future emerge, as they lean into the gale force winds of early recovery. As we get to know them better over time, I invariably see a kind of raw courage and determination, mixed with a new sense of humility and vulnerability that does indeed propel them into a future of hope, often a new appreciation for things lost and regained, and a rediscovery of sacred worthiness that was there all along, but hidden. By the time their five years with us are completed, I think we usually consider ourselves to be friends, and I consider myself lucky to know these men and women of courage as they leave the program and as I have a chance to see them beyond the walls of the committee room.

Our work as physicians can be rewarding, bring great satisfaction, even joy, but it can also be frustrating and stressful, sometimes causing us to question our calling. Doctors are humans and humans are fallible, capable of terrible missteps that can alter not only our own lives but also those around us that we care for. As I’m writing this piece, I have been reading a book by Gregory Boyle, Tattoos on the Heart. In it he closes one chapter with a memorable line worth considering as we do the sometimes difficult work of caring for each other: “Just assume that the answer to every question is compassion.”

Brian Sayers, MD
Chair, TCMS Physician Wellness Program
bsayers@austin.rr.com

Submitted February, 2020

Beyond Burnout: Docs Decry Moral Injury From Financial Pressures of Health Care
By Melissa Bailey



Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn’t need any tests to diagnose the viral infection that causes a rash and searing pain.

 

All those tests? They turned out to be unnecessary and left the patient with over $1,000 in extra charges.

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.

“We’re just shotgunning,” Corl said.

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”

Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase “moral injury” to describe their inner struggles at work.

The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.

That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.

Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.'”

Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.

Those barriers can be particularly intense in emergency medicine.

Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.

These brief encounters may be good for business: They reduce the “door to doc” time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without “being seen,” which is another quality measure.

But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”

Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.

Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy — a recipe for hospital-acquired delirium.

“Hallway medicine is such a [big] part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”

For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.”

Jarman said many emergency physicians she knows work part time to curtail burnout.

“I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”

Also at UC-Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they’ve identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a “huge amount of pain” but could not get surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.

“The health system is not set up to help patients. It’s set up to make money,” he said.

The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

Whether these experiences amount to moral injury is open for discussion. Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.

But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.

Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.

Their work is attracting praise from a range of clinicians:

In Cumberland County, Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the private practice she worked in. She said she saw “a dramatic shift” in the culture there, where “revenue became all-important.” The company cut in half the time for each patient’s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. “I felt I short-shrifted them.”

In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but “I couldn’t offer the care I wanted to because of time restrictions.” One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, “often my job was impossible to do.”

In Chambersburg, Pennsylvania, Dr. Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient’s ailment — and spending nights and weekends slogging through paperwork required by insurers.

“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.” Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.

He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.

“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”

This story was originally published on the Kaiser Health News website. Illustration by Maria Fabrizio for Kaiser Health News.

Brian Sayers, MD
Chair, TCMS Physician Wellness Program
bsayers@austin.rr.com


Submitted January, 2020

A River Runs Through It

 

 

During that last week of the year when I picture myself on a warm beach or by a fire in the mountains, I instead found myself, along with my loyal but somewhat annoyed staff, manually entering “Quality” and “Improvement Activities” data to satisfy my MIPS requirement to avoid Medicare penalties two years down the road. Many of you will have no idea what I am talking about, your practice managers and EMR silently taking care of this each year, but for those increasingly rare souls in small practices wary from hearing complaints about “pajama time” and the other struggles and cost of maintaining an EMR, that tedious time at the end of the year somehow seems worth it.

As I wondered if clinging to my paper charts is a reasonable strategy or if I’m just the proverbial old man hollering at kids to get off my lawn, I managed to waste even more time as I tried to find something that might explain “value based medicine” and how my time with MIPS is worth the effort. MACRA’s QPP (Quality Payment Program) is supposedly part of the pathway to value based medicine. There is, of course, nothing inherently wrong with the idea that being paid to keep people healthy is a better idea for society than primarily paying us to do things for people after they are sick. What I couldn’t get out of my mind was the repeated reference to “value.” Not surprisingly, the word “values” is never mentioned.

In fact, many argue that the very source of what is wrong with medicine, and more specifically with doctors, has everything to do with values, and not nearly as much to do with value. There are certain values that can be traced back to the origins of medicine, ideas like fidelity, compassion, competence, kindness, respect, and responsibility to name a few, that make us as a profession who we are. Many say that physician distress and burnout are the direct results of working in a system that provides little or no incentive, often even obstacles, to our honoring core values of our profession. This time of year when I am most acutely aware of distractions that distance us from honoring values sacred to our profession, I am reminded of a quote from Goethe: “Things which matter most must never be at the mercy of things that matter least.”

There is a river that connects physicians of antiquity to us in our own time, and beyond. The shores that the river endlessly passes are the ever changing shores of advancing science and evolving economics. Both surely change the façade of medicine in every age, and will continue to do so in ways we can scarcely imagine today. But the river itself carries with it certain timeless truths, values that are the same in any age, even if often hidden beneath rushing currents. The river burnishes and refines the stones in its bed, stones that carry messages that if not sought out and given homage, remain hidden at our own peril, words of timeless wisdom from our predecessors that we must both receive and pass on. My favorite line from a lifetime of reading is from Norman Maclean’s, A River Runs through It. It reminds me of being mindful of the heritage passed on through the lineage of medicine.

“Eventually, all things merge into one, and a river runs through it. The river was cut by the world’s great flood and runs over rocks from the basement of time. On some of the rocks are timeless raindrops. Under the rocks are the words and some of the words are theirs.”

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program 
bsayers@austin.rr.com




Submitted, November 2019
  
The Man with a Gun


  
Tony (not his real name) was one of those patients who came to be a friend. I was his doctor for 11 years, guiding him through some very difficult times with lupus. He was a handyman, a fly fisherman, husband, father and a man of deep faith. His condition was difficult to control but he always offered a smile as he patiently and hopefully waded through a series of treatments through the years. I’m a terrible fisherman, neither of the two necessary traits (patience and reading the water) coming naturally to me, but it didn’t keep him from giving me flies that he had tied himself, even giving me a handmade bamboo fly rod that to this day sits in my study closet unused, but treasured.
  
One afternoon during a busy clinic my receptionist urgently pulled me out of an exam room exclaiming, “There’s a man in the waiting room with a gun and he wants to see you… He has some papers.” To this day I’m not sure who or what he was other than a messenger of misery. I suppose he was a constable, but all I remember is him handing me some papers and thinking how ginormous the gun in his holster was, reminding me of a foot long handgun that Mattie pulled out of a flour sack in True Grit, or the gun that a sneering Clint Eastwood/Dirty Harry pulled and pointed, challenging a criminal to try and resist, “Go ahead . . . make my day.”
  
I hadn’t seen Tony for a while and it turned out that he had been diagnosed and quickly passed away with an aggressive malignancy, which a plaintiff’s attorney seemed to think I should have suspected, even in the absence of signs or symptoms as of his last contact with me. This was the era before tort reform in Texas, an era where hardly anyone knew a single physician who had not been sued at least once. Now it was my turn.
  
If you haven’t been through it, it’s hard to understand the emotions you go through during malpractice litigation. In some ways it attacks the very core of who you are as a physician, an accusation that you are doing exactly the opposite of what you swore an oath to do and spent all of those years training to do well. As is often, but not always, the case there was a strong sense of injustice, as I knew I had really done nothing wrong. I was forbidden by counsel to discuss it with friends or colleagues, adding an unhealthy serving of isolation to a plate full of shame and anger. To complicate matters even more, I was simultaneously grieving a man who I considered a generous friend. After a year of silent anguish, second-guessing myself and being suspicious of patients I once felt at ease with, I was as unceremoniously dropped from the suit as I had frivolously been added in the first place. There was a tremendous, but profoundly incomplete, sense of relief. Now even two decades later I still recall those emotions clearly, even as I ironically still treasure the fly rod Tony gave me.
  
As physicians we are called on to be many things by patients, and by ourselves. Compassionate, competent, vigilant, intelligent, patient, available, perhaps even perfect. Litigation, deserved and undeserved, remains a constant threat lurking behind any mistake or just bad luck, but fortunately not as much as some years back. This extreme kind of judgment against us has to some extent been replaced by 100 smaller cuts that we face from criticism from patients or their families, online reviews, peer review, insurance authorization denials, peer to peer reviews, colleagues, employers, practice managers, and at times, most damaging of all, from ourselves. Some of these criticisms are well-deserved, even constructive, and are to be carefully considered as teaching moments, while others are simply based on bureaucracy, greed, frustration or just nastiness. All of them challenge our deep and ultimate calling to bring compassion and love, along with our talents, to each and every interaction with our patients.
  
Even Socrates noted 2500 years ago that “The unexamined life is not worth living” (though he was never “yelped”), so this is nothing new, though now it sometimes seems more personal, more public. Criticism is inevitable in our lives as physicians, as we are visibly out in the world doing things that matter, things that affect other peoples’ lives. Much has been given. Much is expected. We are not perfect. We were not designed to be. Along the way, people will surely assist us in realizing that.
  
Of course, we need to pay some attention to criticism, even when not kindly given. Criticism can be very valuable. Even when expressed inaccurately or with venom, there can be nuggets of truth. But there can also be a destructive element to undeserved criticism and judgment. We have to be careful, perhaps with self-reflection and support from our colleagues and loved ones, that this type of criticism does not harden us over time in a way that causes us to lose the compassionate calling that a younger version of ourselves set out to pursue all those years ago. 
  
Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program 
bsayers@austin.rr.com

 

National Physician Suicide Awareness Day
Tuesday September 17


Submitted September 2019
  
Colleagues,
A few weeks ago we sent out a PWP blog, “My Friend Richard.” Many, if not most, of the PWP blogs sent out to 4000 or so TCMS members go mostly unnoticed. This particular one seemed to strike a nerve with some of you, and most who emailed me or stopped me in the hallway at the hospital afterward had a personal story of a friend or colleague who was lost to suicide, or came very close. 
  
I don’t need to repeat the statistics that you have all heard so many times about physician suicide. I will just take the opportunity on this particular day to remind you to reach out for help if you need it. Once the honest and courageous decision to get help for the sake of yourself and those you love is made, help is readily accessible through family or a colleague or a friend you trust, or through our PWP Safe Harbor Counseling Program. And please, keep an eye out for your colleagues. If you sense they are in trouble, check in with them, say something. You just might be the person who makes all the difference for them.
  
Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program 
  
Check out this video

 

 

Submitted July 2019

 

My Friend Richard

There is something special about that childhood friend. It’s a bond that lasts a lifetime, something we can only experience fully in our formative years. My friend was Richard. We were inseparable in school growing up, then roommates in college, growing into manhood together. When it came time for medical school, I went to Dallas, Richard to Houston where he would start his career. We drifted apart in those years, each in a different world, each of those worlds with its own all-encompassing gravitational pull. I knew he had been depressed at times as far back as high school, but he always seemed to snap out of it. We took a vacation together on a break that last summer and he just wasn’t his old self. I couldn’t quite put my finger on what had changed but he was different. Our minds and energy were so preoccupied in that pivotal time as our careers were forming. A few months later I got the call one evening from a mutual friend in Houston that he had taken his life. As I tried unsuccessfully to piece it all together in the days, then years, that followed, there were fragmented stories of those last weeks, none fitting together. To this day I have no idea if he made any attempt to get help or if anyone tried to help him.   

The current seismic movement in medicine to address physician burnout has its roots in a realization more than two decades ago that we were losing our colleagues to suicide at an alarming rate, much higher than the general population. In the last ten years there has been an explosion of research in this field, with a long overdue realization that the physician wellness crisis has little to do with the personalities we bring into medicine, and everything to do with the environment we are placed in from the day we enter medical school until the day we retire, or change occupation, or worse.   

In the years since the TCMS Physician Wellness Program launched I have heard many stories from my colleagues about frustrations, loss of meaning, even stories of suicides in our community that I was unaware of. I have seen courageous colleagues get the help they needed with counseling or a recovery program, escaping a toxic work environment, cutting hours, developing healthier habits, connecting with colleagues, reconnecting with family or leaving direct patient care. Still, we find in some of our colleagues a certain sense of cynicism or anger or hopelessness, sometimes even a sense of shame that prevents them from getting help.  

In a recent New York Times article, Clay Routledge writes about suicide as an existential crisis and notes that, “In order to keep existential anxiety at bay, we must find and maintain perceptions of our lives as meaningful.” He goes on to say, “How do we find meaning and purpose in our lives? There are many paths, but the psychological literature suggests that close relationships with other people are our greatest existential resource.”  

The point is this. We all need to pay close attention to self-care in the many forms that must take. We need to get help from professionals and lean in to our family and trusted friends when we sense trouble and listen when those around us express concern. We also need to look out for each other. Check in with colleagues, especially if you sense they are struggling. What you think might be an awkward conversation with a friend might just save someone’s career, or their marriage, perhaps even their life.   

My friend Richard may be the best friend I’ll ever have. I have many happy memories of growing up together, but also regrets. It is a difficult story even four decades later, but there is a happy ending of sorts, as his story, along with the stories of struggles of so many of our colleagues through the years, people you have seen in crisis, perhaps even your own story, are all embedded in this program and our growing desire as a community to be there for each other. 

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program 

 

Submitted June 18, 2019


Editorial Note: Our guest writer this month is Claire Miner, PhD, LPC. Dr. Miner is one of our PWP therapists, specializing in couples counseling. She can be accessed through our anonymous Physician Wellness Program coaching/counseling program by calling our confidential help line at 512-467-5165 or using the contact information at the end of her article.

CULTIVATING INTIMACY IN YOUR MARRIAGE  

My friend is a gardener. Her flowers respond well to her care and attention. Some plants thrive with just a bit of water and sun, while others require fertilizing, a certain climate, and weeding to assure growth. In your “life garden,” you nurture your children and community with attention and resources. But is your marriage getting consistent “tending”? Even a healthy relationship will blossom with focused care. John Gottman’s Seven Principles for Making Marriage Work can point the way:  

1. Enhance Your Understanding of Each Other 
Know your partner and keep abreast of changes in his/her life. You know all the basic stuff, but do you know your partner’s inner world, such as his/her stresses, worries, aspirations, dreams?   

2. Build Fondness and Admiration 
Friendship is the foundation for passion and romance, and affection and respect are an important basis for friendship. Communicating the areas that you appreciate in each other will increase positive feelings.   

3. Turn Towards Each Other 
Everyday moments when people connect with each other are the building blocks of all relationships. “Turning toward” with emotional support, shared conversation and humor, exchange of interests, and affection will increase the positivity in the relationship.   

4. Accept Influence from Your Partner
Being able to “yield to win” means that you won’t be a roadblock to change, and that you’ll be able to make your partner feel valued and respected. Focus on how to stay engaged and connected to your partner, rather than winning the argument.  

5. Solve Your Solvable Problems
Couples in long-term, satisfying relationships have learned skills to solve the problems that can be solved in their relationship. These skills are not innate; we can all learn them—for example, starting a conversation gently and compromising.  

6. Learn How to Talk about Perpetual Problems More Easily
Some issues between couples will never be resolved. The best that can be hoped for is to be able to find some humor in them and to be able to talk about them more gently and easily with acceptance, so that they are not great sources of pain.  

7. Create a Vision for Yourselves as a Couple
One of the tasks of couplehood is to create shared meaning. Finding a vision to work towards together will enhance your sense of “we-ness” and keep you bonded as you move through time together.  

Dr. Claire Usher Miner, PhD, LPC, Certified Gottman Couples Therapist, can be contacted at 512-689-7105.

 

 

Submitted May 10, 2019

 

Caduceus

  

Last month a couple of us from the medical society’s Physician Wellness Program spent a few days in Yellow Springs, Ohio at a training workshop conducted by physician wellness pioneer Rachel Remen, hoping to bring her well known Finding Meaning in Medicine small group program to TCMS. It was a transformative time spent with a collection of bright, motivated physicians mostly from prestigious institutions, who displayed exemplary humility even in the presence of a goofball like me. One of the group prompts was to bring a small object from our home or work that held some symbolic significance for our work. In one of the groups, someone had brought a small caduceus lapel pin given at medical school graduation. It reminded me of the power symbols can have, emotions they can trigger, stories or habits they can remind us of. 

The caduceus is the classic symbol of our profession, its familiar gold staff, wings at the top and two serpents wound around it, tangled and climbing upward is actually different from the simpler, ancient version, the rod of Asclepius. A number of stories as to its meaning and origin exist. As Daniel Sulmasy recounts in A Balm for Gilead, the use of caduceus is derived from a story about Asclepius, the physician hero-god of Greek mythology from whom Hippocrates claimed lineage.  

According to mythology, one day Asclepius was called to help a man who had been struck by lightning. While trying to save the man’s life, a snake came up beside him. Multitasking as physicians through the ages have, he quickly struck the serpent with a staff, killing it, then turned his attention back to his patient. Soon after another snake appeared, carrying herbs in its mouth which it promptly placed in the dead snake’s mouth. To the amazement of Asclepius, the dead snake was soon brought back to life. Taking the example, the mythological father of medicine took some of the herbs and placed them into the mouth of his own patient who was quickly healed.  

Rich in symbolism, the story makes an important point about us as physicians and mortals. In classic literature the snake is often a symbol of our imperfections. Within that context, we see one serpent coming to the aid of another wounded serpent, then together climbing up the staff and away from their worldly moorings, healer and healed becoming as one, an image worth considering. We are instilled with a yearning to be like the winged staff, strong and reaching upward, but compelled to recognize that, like the serpents, we are vulnerable and in need of each other. It is the humility and response to this commonality, this broken oneness with all around us, that can make us healers in the best traditions of our profession, our ethics, our faith.  

On the flight home, in that rare space where we might have a couple of hours to think, I considered again the trajectory of medicine in general and my own practice in particular. We all explore, in our own way, how we might become the kind of physician, the kind of healer, that occupied our dreams as our paths in medicine were being formed. Perhaps that will come from an ultimate realization that to be a great physician, rather than being the smartest person in the room, we need only be the kindest.  

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program 

 

Submitted March 25, 2019  

 

 

 

 

 

Faith, Hope, and Transformational Leadership  

I went back to school well into middle age and in class one day during a discussion on icons and Saints, the professor recommended that in the space where we work, relax or spend creative time, along with family photos we sprinkle in a picture or two of other people who somehow inspire us. It is a practice I had discovered years earlier and in my study are pictures of Abraham Lincoln and Johnny Unitas. The picture of Lincoln is just before his assassination in 1865, haggard and dramatically aging, but with a hint of a smile as the war came to an end. The picture of Johnny Unitas, the premier quarterback of his era and my childhood, is from the 1958 NFL championship game against the New York Giants, often called “the greatest game ever played.” It was the first nationally televised pro football game, a game that brought the NFL into the modern era. In the picture Unitas is raring back in classic drop back quarterback style to launch a ball far downfield that would tie the game up and move it into overtime. It may seem strange to think that these two diverse pictures could both inspire me or have anything in common, but they do.

Like many people, I am amazed and inspired by Lincoln’s life, rising from abject poverty, loss of his mother and beloved sister at an early age, an adversarial relationship with his father that he eventually escaped. As a young lawyer he developed lifelong depression that was so bad his doctor noted, “He was within an inch of being a perfect lunatic for life.” At one point his friends hid sharp objects and guns from him and Lincoln himself noted, “I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth.” In the midst of this, Lincoln suffered political defeats and all kinds of personal abuse, but found a profound sense of purpose in the antislavery issue and that sense of purpose and meaning propelled him to the presidency, and immortality, against great odds.  

I recently read Doris Kearns Goodwin’s book “Leadership in Turbulent Times,” in which she describes Lincoln’s form of leadership as “transformational leadership,” that is, leadership that focuses on future goals and purpose rather than more expedient “transactional leadership.” In the many books that I have read about Lincoln I’ve come to see that Lincoln’s transformational leadership applies not only to leading those around you towards a greater good, but, perhaps more importantly, it is an internal leadership that lifts us as individuals to lives of meaning and purpose. Martin Luther King, Jr. famously said, "The arc of the moral universe is long, but it bends toward justice," and though it would be a century before that quote was spoken, Lincoln surely felt that same certainty, in part from his faith, but also from a deep confidence that he possessed the skills and determination to make a difference, just as each of us can in our own lives. 

Johnny Unitas was from humble origins as well and early on nothing about him seemed remarkable or destined for greatness. Just three years before he played in that epic championship game, he was working construction and playing semi-pro football for six dollars a game. His sheer determination, confidence and quiet leadership were the hallmarks of his career. On that particular day, in an instant frozen in this photograph, he was poised to launch a long pass. 60,000 eyes would be pointed skyward while in the quarterback’s heart there was not only hope, but also a sense of certainty that the arc of the pass and the receiver sprinting downfield would connect in just the perfect spot, at just the perfect time. But more importantly, what inspires me when I look at the picture is the sense that there was also a certain kind of faith and resilience, a confidence that even if that particular pass fell to the ground, they would pick themselves up, huddle up and try again. There was an unspoken sense that his leadership, optimism and love of his work could make all the difference, attitudes critical in our own lives as physicians. 

Who inspires you? 

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program 

 

Submitted March 12, 2019

A Surgeon’s Wellness Instruments: Empathy, Scalpel, and Music  

Music has a primal power to impact quality of life whether it creates healing, happiness, self-expression, human connection or calm. Austinites, as listeners and performers, know that as well as anyone. Most of our lives are imbued with music; in restaurants and retail shops, in our cars and trucks, our late-night watering holes. We play music and it takes us away, to re-connecting, remembering, re-energizing.  

When we are ailing, music can be soothing or pleasantly distracting and help with pain or worries. When most of us walk into a doctor’s office, our blood pressure rises about 10 points, our heart rate rises, and we feel anxious. When we are told we need surgery, that is a whole other level of stress. Music plays a big role for both my patients and me in the operating room. It can provide connection and calm.   

After I talk with a person and examine their shoulder, elbow or hand, I arrive at a diagnosis. If I feel surgery is truly the best option for them, I recommend it. And then there is a pause, a reflection and a moment of wonder. I am always moved by my patients’ sudden and extreme faith. It is as if they are saying, “I just met you like 15 minutes ago, but sure, cut open my body. Take saw blades, scalpels, drills, screwdrivers, and chisels to me as needed. Whatever you think.” I am humbled by their trust. At the same time, I see “healing with steel” as actionable empathy. As surgeons, we listen, hear, see, understand, enter and attend. With this primal connection, this precise and sensitive action, we can alter the quality of a life.   

On the day of surgery, I greet my patients on the gurney, and I can see the anxiety in their eyes. I say, “I know you’re worried, but I am confident that the surgery will go well ,and you will feel much better.” Then I say, “I always play music when I’m operating. You may not remember much of it, but what would you like to hear?” They always perk up with this. Most often, they say, “Whatever you want to listen to; I want YOU to be relaxed.” I tell them, “I like almost everything. And I’m always relaxed in the OR. It’s my happy place.” Then I might hear, “The Beatles!” or “I’m a classic rocker” or “classical” or “anything except what my 17-year-old plays these days . . .” This choice, this brief moment of control, this conversation about music, just before “going under,” has a calming effect.   

Despite being in practice for over 20 years, I am continually inspired and intrigued by people’s stories; what they do, how they live, who and what they love. In addition to diagnosing their medical concern, it is so fascinating to learn what makes someone tick or creates a lift– the Talking Heads, fly-fishing, angel hair pasta, the banjo, rock climbing. The music they love.   

 

O. Alton Barron, MD 
Dr. Barron is an orthopedic surgeon with ATX Orthopedics and is a 
Clinical Associate Professor of Orthopedics at Dell Medical School


Submitted January, 2019

Maybe It's Time

During the holidays I was running some errands, half listening to a rerun of some financial show on the radio. I was mostly ignoring it but then they said a couple of things that got my attention. One was that time honored disclaimer “Past performance does not necessarily predict future results,” followed by “the best way to predict the future is to create it.” Both are rich material but the second one, a well-known quote attributed to Lincoln, caught me at just the right time. 

The transition from one year to the next is often a time when we might become somewhat introspective about where we are in life, how we might improve things, and what we need to leave behind. Positive change requires careful assessment of what our current state of existence is, then the difficult task of deciding what to shed, and what form transformation might take. Sounds exhausting. You might think that the only things that need to be shed are bad habits, or things that clearly work against our happiness and success. You might be wrong. 

In the world of business and organizational development, “change management” is a critical component of success and is now a well-established discipline in that world. Large organizations have executives whose entire job is to help the organization evolve and survive by strategically planning how to take a successful organization and pump new life into it every few years. It is a critical key to long term survival. 

As I considered this, I reread Halftime by Bob Buford. A couple of the themes in the book are interesting to think about. The first is “the sigmoid curve.” Organizations that get off the ground and do well go through a fairly predictable cycle of formation, development, growth, then the pinnacle of success, but then an equally predictable decline if change is not part of the organization’s culture − if it does not, or cannot, evolve. Once that decline begins it is hard to reverse. You need look no farther than Sears, Toy R Us, shopping malls, bank lobbies, World Book Encyclopedia and other bygone successes that are failing or breathing their last gasps. The sigmoid curve holds that the time for change is during the height of growth and success − before decline − while there is still creativity, enthusiasm, and resources to bring about change that will perpetuate success. It is profoundly counterintuitive as it calls for the organization (or individual) to leave behind some of the things that actually created success in the first place in order to achieve more lasting relevance. Buford’s second point is that this constant, difficult evolution in people, is ultimately an evolution “from success to significance.” 

Most physicians are highly successful in their practice, but how many go on to achieve not just success but also significance, and not just in their work (which is no small thing), but also in something that transcends work and is all encompassing in their own lives and in the lives of those around them? This kind of change is not about giving up core values and beliefs, things that are timeless and help us weather life’s storms, but is more about defining priorities, how we go about our work, who we work with or for, and how we nurture and cherish family and friends. Ultimately, it is about how we embrace change at each unique stage in our lives, in order to fill our lives with meaning, generosity, and love that spills over into the world around us. That kind of change is the difficult work that defines our lives. 

It may seem odd to quote Bradly Cooper, and this will probably (hopefully) be the last time, but as I was writing this I happened to hear his song from A Star is Born. It’s not exactly Shakespeare but it’s a fitting thought to close with.

Maybe it's time to let the old ways die.
Maybe it's time to let the old ways die.
It takes a lot to change…
Hell, it takes a lot to try.
Maybe it's time to let the old ways die.

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program

 

Submitted November, 2018

True North

My oldest child is grown now with a career and a growing family, but he used to just be a kid, and like all children, he needed a bedtime routine. All too soon he lost interest in bedtime stories but we still needed a way to wind down together at bedtime. In those days a set of encyclopedias was still on the shelf and for a while we ended the day exploring the world together in those books. We would randomly select a volume, then flip it open read about whatever was on the page we landed on. It’s surprising how many of those random facts I still remember today. One evening we read about “true north.”  

I always thought that a compass points to the North Pole. Like so many other things, I was wrong. True north is the direction along the earth's surface towards the geographic North Pole. It is almost identical to astronomical true north, calculated for centuries by ocean bound navigators. It is a static, predictable point mariners have depended on since man began to travel.  

Magnetic north is a wandering point in the northern hemisphere where the planet's magnetic field is vertically centered. It is the direction compasses point. Magnetic north varies slightly from year to year, altered by natural and man-made magnetic fields. Following magnetic north as a navigation strategy over long distances to precise points will inevitably cause us to become lost, as ancient mariners knew.  

And so all these years later, this fun fact I learned with my son one evening returns to haunt me (and now you) as a metaphor. In life's journey we are often uncertain where we stand, where we are going and what is the right path. True North is the internal compass that guides you successfully through life. It represents who you are as a human being at your deepest level. It is your point of orientation - your fixed point in a spinning world - that helps you stay on track as a leader and as a human being. Your True North is based on what is most important to you, your most cherished values and beliefs, your passions and motivations, the sources of satisfaction in your life. Ignoring or leaving True North unexamined is dangerous and can rob life of meaning. Finding and following True North is the difficult work that defines our lives.  

When it comes to vocation, we might consider True North as another way of describing our calling—how we match what is deep within our heart and the unique gifts we have been given, with what the world cries out for in need.  

I speak to physician groups frequently about burnout and wellness, and many times I have flipped through my well-worn power point slides about both. More and more it occurs to me now that most of these slides are ultimately useless unless we as individuals spend more time exploring, discovering and then tenaciously following our own unique True North.   

Most of us were in small practices when my career began, now 70% of physicians are employed. Often, our professional lives are influenced, if not controlled, by people far removed from the realities and sacredness of the exam room. To practice in an environment that ignores the importance of things like calling, relationships, values, respect and meaning, instead focusing most visibly on profit and market share, devalues the humanity in our work and its wake can land us as individuals onto a rocky shoreline before we even realize we have strayed off course. Self-examination in medicine these days requires not only examining what is deep within us, but also what we allow to go on around us. If our own values and calling are in conflict with the practice or organization we work within, we go to work each day in great personal peril. Fortunately, we have some great leaders in our medical community, many of whom support the Physician Wellness Program, who are increasingly committed to physician wellbeing. Be a voice within your organization. Watch out for your colleagues. We still have a long way to go.  

 

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program

 

Submitted September, 2018

The Cloud of Witnesses


During my years in study at an Episcopal seminary, I came to appreciate the reverence Episcopalians have for the saints. There are hundreds of recognized saints and one semester I spent several months studying some of their life stories and the spiritual gifts they left behind. The Old Testament refers to the "cloud of witnesses," the faithful who pave the way for subsequent generations. Of course, the importance of the heritage of important figures in inspiring and giving us direction is not unique to religion. As Americans, we venerate the founding fathers, Lincoln, King, and many others. There are legendary athletes that sports fans compare modern day athletes to, as well as educators, authors, scientists, social activists. Imperfect as they were, their life stories are guideposts of inspiration. Medicine is no exception. Lister, Curie, Freud, Fleming, Jenner, Osler, DeBakey, and so many other giants along with the teachers and mentors who paved the way for us. The cloud of witnesses is sometimes likened to the crowd that cheers you on as you run a marathon or 10k. Often nameless and faceless, but full of those who care about us, want success for us, cheering us on.

For the last few years, I have had the honor to write memorials in the TCMS Journal for our departed colleagues. Some were well known to me, others I never met. Given the generation now passing, most are male, almost all served in the military, the majority trained in Texas or the south. The women of that generation who have passed serve to create a very special witness to our profession, their unique obstacles as women in medicine in that era an especially rich heritage. As I piece together their lives, not surprisingly what stands out more than the accomplishments that punctuated their lives is the heritage of compassion, accessibility, friendship, and faithfulness they imbedded in the hearts of the lives they touched. Poet David Whyte notes, "Death is not impressed by what we have done, unless what we have done leaves a legacy of life...what is remembered in all our work is what is still alive in the hearts and minds of others.” I often think of doctors who I have worked with, along with mentors and teachers who are gone now but gave me gifts that I still call on today. They likely had no idea that I would see things in them that I would carry with me that make me a better doctor and a better man.

We accomplish much in our lives as doctors. We make lives better, cure or control disease, and, on a good day, even connect with patients and bring real healing, often against great odds. We should not lose sight of the fact that connecting with colleagues, being available to listen and advise, to be an encouraging and compassionate presence, is one of our primary callings and ultimately is the most important thing we leave behind to our colleagues and our profession. 

These are difficult times to practice medicine. We know that burnout is all around us – statistically about half of us – and not just the usual irritations of work but true burnout with life altering effects that shade all phases of our lives as well as impacting patient safety. Keep an eye out for colleagues who may be struggling, check in with them, encourage them to get help or at least talk about it. Realize it or not, your life is an example to those around you and there are unseen opportunities to help your colleagues who may need help but don’t get it out of shame or denial.

 

Brian S. Sayers, MD
Chair, TCMS Physician Wellness Program

 

 

Submitted July, 2018

The Hero’s Journey


Since childhood, one of my favorite stories is David and Goliath, the story of the young, future king who finds himself – by a combination of chance and choice – facing the Philistine giant.  The fate of his army depends on him alone, with only his wits, faith and courage to perform a seemingly impossible feat.  We might all identify with this story, as we have all felt ourselves to be an underdog at some point in our lives.  As I was preparing a class about this story recently, I came across an essay about the “monomyth” or “The Hero’s Journey.”  Described by author Joseph Campbell and others, the Hero’s Journey is a basic story pattern throughout mythology, a pattern frequently found in other ancient writings as well as later day literature and film. 

A very brief summary of the stages of The Hero’s Journey is as follows: the hero from the ordinary world is called to adventure.  After initially refusing the call, he crosses the threshold into a supernatural region.  He descends into “the belly of the whale” and “the road of trials,” along the way meeting with helpers, mentors, a goddess, a temptress, and seemingly insurmountable challenges. There is atonement with a higher power, then receipt of the boon (treasure) and apotheosis (achievement of a higher level of existence), finally rebirth and return to the ordinary world, now possessing gifts to bestow on humanity. 

Literature is often a reflection of everyday life, and if we spend a little time thinking about it we may be able to see many small, and perhaps a few large, monomyths in our own lives.  Our lives in medicine these days is easily seen through this lens.  We pass through a certain threshold from our early lives into a life of medicine, lives that are full of mentors, challenges, temptations and perhaps dark times spent in the “belly of the whale.”  But like the heroes in many of the stories, as we navigate difficult times the treasure that we acquire may be a certain kind of knowledge, perhaps even wisdom, a boon that we are called to share with our colleagues and all of humanity, one patient at a time.  To achieve and then share the gifts that we attain on this journey is indeed heroic, anything but ordinary, but often obtained at great cost.

Different authors describe The Hero’s Journey in different terms, but all include the importance of the “mentor” or “supernatural aid” that assists in the journey.  We may find this assistance in several ways.  One is deep within our own souls, beyond ego where our deepest desires and meaning lives, a place it takes some effort to reach.  Another is found within our community of colleagues, bound together with common hopes and goals, supporting each other, sometimes going arm and arm down the “road of trials,” then hopefully beyond it.  Lastly, there is something woven within, but also beyond, both of those.  On my desk I have a fortune from a fortune cookie with a well-known saying: “Act boldly and unseen forces will come to your aid.”  The ambiguous sounding “unseen forces” is open to individual interpretation.  In my own life it means something very specific, but beyond that, the saying is significant in calling on us to whine and retreat as little as possible in the face of life’s important challenges, but rather to act boldly as we carry our gifts and dreams into a world in need, regardless of obstacles in our way, and to do so in a way that breathes life into us and those around us.

 

Brian S. Sayers, MD
Dr. Sayers is Chair of the TCMS Physician Wellness Program 

 

 

Submitted April 30

An Endangered Species, or an Evolving Species?

In an article from the last issue of the TCMS Journal, Dell Medical School Dean Clay Johnston, MD, PhD,  makes insightful observations about the future of practicing physicians and the mindset we will need to remain relevant. Are physicians, at least as we have traditionally considered ourselves, really an endangered species? He observes what many of us have already grudgingly concluded: that the capabilities of AI (artificial intelligence) will increasingly replace much of the data storage and problem solving tasks that physicians have traditionally seen as their own unique gifts. As this happens rapidly and predictably, what will be the role of physicians? Will that new role be an entirely new direction for us, or a return to the deepest roots of the healing profession?

Dr. Johnston notes that the way medical schools train physicians will need to undergo a sea-change to prepare the next generation of physicians: “Most allocate substantial time to memorization and analysis, tasks that will become less demanding as artificial intelligence improves. But components of the art of caring—communication, empathy, shared decision-making, leadership, and team-building—are underemphasized, when they are emphasized at all… It’s essential that medical education leaders rebalance their curricula toward these components. Doing so will help patients receive the best care that medicine and machine have to offer. It may be good for physicians as well, as they find more opportunities for meaningful patient communication and delivery of higher-quality care.” 

Dr. Johnston notes, “We know that the art of caring is central to the medical profession.” Indeed, it is one of the few things that AI cannot replace. Physicians will need to remember that curing and healing are not the same and our call as physicians in providing care is to endeavor to restore wholeness to the person, not just the body.

How do we realign this mindset as a profession? Daniel Sulsmasy, in his article, Is Medicine a Spiritual Practice?, observes that for physicians to really connect with their patients they must be willing to explore, or at the very least acknowledge, that patients struggle with “the big questions. What is the meaning of my illness? Why must I suffer? Is there anything about me that is valuable now that I am no longer ‘productive?’... Can my doctor possibly understand what I am really going through? A physician who has begun to explore these questions in his or her own life will be better prepared to help patients struggle with these questions.” 

Brian S. Sayers, MD
Dr. Sayers is Chair of the TCMS Physician Wellness program

 

Submitted March 28

The Medical Marriage

Medical Marriage-photo
Adam Taylor/ABC via Getty Images

First the good news.  Contradicting earlier studies with potentially flawed designs, a study out of Harvard  that looked at data from 6 million people, including 40,000 physicians, found that physicians, 27% of whom reported ever being divorced, are actually less likely to divorce than the general population of non-healthcare employed people, 35% of whom had been divorced.  Broken down into healthcare professionals, we stack up well again, less likely to have experienced divorce than dentists, healthcare executives and nurses.  

In spite of this good news, married physicians face unique challenges to be navigated.  Our work as physicians can be highly stressful and involve long hours physically (or emotionally) away from our families.  We often bring these stresses home with us.  The traits that can make us excel as physicians as often as not may make us a challenge to be married to.  Women in medicine often face an additional set of challenges balancing work and family life and are 1.5 times more likely to have been divorced than their male counterpart of similar age, with women physicians working more than 40 hours per week at particular risk.  

So what is the key to a successful medical marriage?  A number of strategies have been suggested.  One study from Mayo Clinic looking at factors that work for and against the medical marriage from the spouses vantage point demonstrated that “on multivariate analysis, minutes spent awake with their physician partners each day was the strongest predictor of relationship satisfaction, exhibiting a dose-response effect.”  Other studies have also identified time together as the key, although at least one has demonstrated that quality time is really the key with spurts of just 30-120 seconds of “caring interaction for a total of 20-30 minutes a day,” to be a key predictor of marital success (Sotile/Fraenkel).   By any measure, time with your spouse is a critical ingredient, also one very difficult to navigate when so much time and emotional energy are consumed by career and the “parenting vortex.” 

In April, the TCMS Physician Wellness Program is proud to add a Certified Gottman Couples Therapist to our coaching panel for couples in need of expert help in making their marriage the best it can be.  Here is more information about couples coaching as well as our coaching program.

 

Brian S. Sayers, MD
Dr. Sayers is Chair of the TCMS Physician Wellness program

 

 


Submitted March 5

When 20% is a Passing Grade, but Surprisingly Hard to Get

Last fall I attended a nationwide conference on physician burnout and resiliency in which a researcher from Mayo Clinic presented data about causes of physician burnout.  In the study, they looked at certain characteristics of physicians who fulfilled criteria for burnout and those who did not and tried see how the two groups differed in certain categories

They asked participants to identify what work related activities they find most meaningful.  Examples included direct patient care, administration, research and education activities.  They found that physicians who spend at least 20% of their time on their most personally meaningful activity have a burnout rate that is half of those who spend less than 20% of their time on favored activities.  It is, of course, both amazing and frightening to think how many physician fall short of that low percentage in their workday, but not surprising what the consequences are.

Shortly before I sat down to write this, I listened to a podcast during a run that featured Shawn Achor, an expert in positive psychology. In describing the “secrets of happiness” he notes the importance of redefining how we think of happiness.  His argument is that if we define happiness only in terms of pleasure or the final accomplishment of a goal, then happiness is never more than a fleeting moment in time.  He calls on us to see happiness as primarily being “the joy we feel while striving towards our potential.”  The potential he refers to is our ultimate capacity for optimizing relationships, vocation, and other integral aspects of our lives.  Intimately linked to realizing joy and happiness, he argues, is a sense that the things you are involved in have meaning.

As we try to navigate our professional careers towards happiness and fulfillment, an important call is to recognize what part of our work is most meaningful to us and to make sure that in the course of a normal workday that activity is consistently and proportionately represented.  

What specific activity is most meaningful to you?  How well is it represented in a typical day?                    

 

                                                                                   -Brian S. Sayers, MD
                                                                                     Dr. Sayers is Chair of the TCMS Physician Wellness program

 

 

Submitted Febuary 2

Healing From Within

I have been an internal medicine physician for over two decades and have traveled the world both as a missionary physician and a tourist. When I am home in the United States, I can feel a palpable and growing level of stress in our communities across America, as evidenced by the ever-increasing opioid crisis, alarming rates of obesity, rising statistics of violence, depression, and sadly, suicide. This level of stress is much higher in the United States than other countries I visited. I have felt helpless for many years, not really knowing how to treat my patients facing stress-induced diseases. How could I? Like many of my colleagues, I was practicing with burnout symptoms for many years.

Then, in 2009, I had a personal tragedy so horrific that I knew prescription medicine could not help me to heal. I had to find a different way. I was encouraged to try meditation. Despite my skepticism, I decided to put effort into the daily practice of meditation. To my surprise, it worked. It not only took away the emotional pain and burn-out symptoms but replaced it with a deep joy that is difficult to describe.

This led me into research for the next several years on why and how meditation heals. What I found was substantial research in meditation in major universities throughout the United States, particularly at the University of Massachusetts and Harvard Medical School. Meditation is offered as treatment for many conditions including hypertension, depression, anxiety, ADD/ADHD, just to name a few. Meditation reduces complications to chemotherapy, radiation therapy, AIDS treatment, surgeries, and the list goes on and on. Meditation works because it counteracts the stress response creating a relaxation response that allows the body to heal. It is now considered a significant evidence-based practice in medicine.

Meditation is currently widely used in many occupations. It is being adopted in the military for stress and resiliency. In the corporate world, companies such as Google, have incorporated meditation into the work day as it has shown to improve morale, focus, less sick days, and increased productivity. Schools are using meditation instead of detention, showing improved attention, behavior, and grades. Even in sports, professional football players and Olympians use meditation daily to help their focus.

I practice a meditation called the Centering Method, a mindfulness meditation. It is a simple method that elicits the relaxation response when practiced daily. I brought this meditation practice to physicians in 2014. We now have ongoing workshops at setoncove.net.

Meditation has been practiced for thousands of years. However, we have only started to study its benefits. I see a future where we learn that the power of healing is truly within each of us.

Anna Vu-Wallace, MD
Dr. Vu-Wallace is a hospitalist and is founder of the Mindfulness Meditation Clinic at Seton Cove

 

Submitted December 31

Thresholds

The beginning of each new year often becomes a sort of artificial but important threshold, a time when we look back on the old, both regrets and joys, and wonder about the year to come. Some years when happiness and abundance have marked our year the transition is easy, almost entirely unexamined, while other years, recent events of loss or regret challenge us toward self-examination and change. To acknowledge and navigate significant change, a threshold, in any meaningful way requires honest reflection and courage. The late poet John O’Donohue commented on such times of challenge:

“To acknowledge and cross a new threshold is always a challenge. It demands courage and also a sense of trust in whatever is emerging. This becomes essential when a threshold opens suddenly in front of you, one for which you had no preparation. This could be illness, suffering or loss. Because we are so engaged with the world, we usually forget how fragile life can be and how vulnerable we always are. It takes only a couple of seconds for a life to change irreversibly. Suddenly you stand on completely strange ground and a new course of life has to be embraced. Especially at such times we desperately need blessing and protection. You look back at the life you have lived up to a few hours before, and it suddenly seems so far away. Think for a moment how, across the world, someone’s life has just changed – irrevocably, permanently, and not necessarily for the better – and everything that was once so steady, so reliable, must now find a new way of unfolding.”

Sometimes thresholds are abrupt and dramatic as O’Donohue describes. More often, arrival at one of life’s thresholds is more subtle, but no less profound and challenging to discern and cross. In such times, we need to call on not only the invisible strength found within us, but also the support available from those around us, to produce visible and productive change. As he goes on to note in his poem “For the Interim Time,” during such times,

“What is being transfigured here is your mind
And it is difficult and slow to become new.
The more faithfully you can endure here,
The more refined your heart will become
For your arrival in the new dawn.”

We hope the old year ended with happy memories, gratitude, and professional satisfaction and that the New Year will be full of family and friends as well a sense of purpose and meaning in your work. If you find yourself in a time of challenge and in need of help, please consider reaching out to the PWP confidential coaching program, where one of our professional counselors is only a phone call away.

                                                          -A physician

Submitted November 29

It’s the Most Wonderful Time of the Year (?)

In the midst of digging out of the colossal mess left over from our great family gathering at Thanksgiving, then bringing down the seemingly endless boxes of Christmas decorations from the attic to sort through, I convinced myself it might be therapeutic to read about survival/enjoyment during the holidays. Here’s a few of the most common tips: 

  1. Gratitude. Expressing gratitude on a daily basis and in tangible ways (verbally or in writing) is incredibly powerful. There is a whole body of literature about the measurable and life changing mental health benefits of this practice. Spend a little time reading about it or look at some links and videos about gratitude at tcms.com/Education-Resources
  2. Reconnect with your faith or spiritual practices. Plan out quiet time, walks, reading sacred texts, poetry or other inspirational writings or find time for worship and thanksgiving.
  3. Reconnect with family and friends, and not just texts and emails but something relaxed and unrushed. If they are not nearby, surprise them with an actual phone call. If they are close by, share a meal or meet for coffee or do something without a lot of time pressure.
  4. Avoid toxic people or situations. You know exactly who and what this means. Enough said.
  5. Enjoy some unscheduled, unstructured time. There is great power and rejuvenation in the fine art of “goofing off.”
  6. Unplug. Find time when someone else is on call to turn off your phone, your computer and forget the emails. You might just have a chance to get to know yourself, your family or friends with distractions missing.
  7. Go outside. Take a “nature bath.” There is surprisingly robust research about the mental health benefits of spending time in nature.
  8. Take care of yourself. Holiday food and drink is everywhere. A little moderation and some exercise won’t kill you.
  9. Forget about finding the perfect gift. It doesn’t exist. As you fret over gifts, reconsider generosity. Be generous with your time and your love.
  10. Keep a mental scorecard. Which one is leading, the “stuff” or meaning and connections? If the stuff gets too far ahead, it might be time for a coaching change. 

Can this be the most wonderful time of the year? Absolutely! It should be full of family, friends, fun, rest and meaning. It just takes the right mindset and maybe the ability to pause and take a deep breath every now and then.

If are struggling and think you might need a little help, consider calling the 24-hour confidential PWP coaching hotline 512-467-5165 and we will help you connect with one of our TCMS counselors by phone or in person.  

                                                        -Happy Holidays!

Submitted November 7

On Being Perfect

Compulsive, perfectionist. Personality traits often blamed as root causes of physician burnout. There is a part of perfection seeking that makes us better doctors, but another part that can be profoundly destructive. When we fall short of our own expectations, either through our own missteps or because of things we cannot control, with the wrong mindset it can send us into a spiral of self-doubt, hesitation or defensiveness that impairs our ability to provide good care for patients, and ourselves. 

No matter how hard we try, sometimes things go wrong. It is part of our lives in medicine, life in general for that matter, which goes against our quest for perfection, a quest we take on in equal measure for our patients and our egos. At some point we have to come to terms with imperfection, with failure, and see these events for what they are and what they teach us and at some point redefine what perfection really means.

I am a sucker for old sports movies as they study not only those who succeed, but also those who seemingly fail. My favorite scene in Friday Night Lights is the halftime pep talk that the coach, played by Billy Bob Thornton, gives during their championship game:

“…You got two more quarters and that's it. Now, ya'll have known me for a while, and for a long time now you've been hearin' me talk about being perfect…To me, being perfect is not about that scoreboard out there. It's not about winning. It's about you and your relationship to yourself and your family and your friends. Being perfect is about being able to look your friends in the eye and know that you didn't let them down, because you told them the truth. And that truth is that you did everything that you could. There wasn't one more thing that you could've done… Can you live in that moment, as best you can, with clear eyes and love in your heart? If you can do that gentlemen, then you're perfect.”

As physicians, perhaps we should learn a lesson from the coach, redefine perfection and know you can achieve it, regardless of the outcome, when you can look into the eyes of your patient, and into the mirror, and can truthfully say you did everything you could, there wasn’t one more thing you could have done, and say it with clear eyes and love in your heart.

                                                          -A physician

Submitted October 6

Compassion

I was the senior resident in the ICU. It was late and I was exhausted. A sleet storm was in progress outside the hospital and miles away in a remote area in far northern New Mexico a blizzard was in progress. Somehow Life Flight had managed to get out ahead of the storm and transported Roy to County where he landed on my service. He arrived in cardiogenic shock with ominous tall, wide ST elevations that we identified as “tombstones,” signifying what in those days would as likely as not be a fatal event.

The usual frenzied dance followed, using protocols that sound primitive now, all the while knowing his chances were slim. He rallied after I had sent the interns and students off to get a little sleep, was even oriented and conversant for a while before the arrest and futile code. He told me about his ranch, snow covered now, but soon, in the spring, lush green pastures would re-emerge in a valley below two tall mountains, snow fed streams coursing through the valley. A family ranch where his wife was now stranded in the storm, and where tomorrow his son would have to try and drive the pickup into the pasture, his grandson pushing square bales out into the snow for the cattle as they went along. The old man’s face was pale, deeply creased, sun damaged, and now with tears. I think that night was the first time I held a patient’s hand for more than an instant, in this case for an hour or more, his hand clutching mine at times. By 7:00 a.m. my shift was done, and so was Roy. I called his wife then headed home, and slept.

We have talked about physician wellness a lot lately and it occurs to me that at the core of it lies compassion, of sharing the suffering of others. Burnout and compassion travel against each other with opposite trajectories, one always ahead of the other. Our lives in medicine are defined by compassion, both in giving it, but also in feeling worthy of receiving it. We might ask ourselves many times in a long career, “How do we nurture and protect it?” Without compassion, we are just technicians.

Even today I will sometimes see a cardiac monitor in the unit and think of Roy. Most years, driving to a favorite spot in Colorado I will pass by a certain wide pasture, emerald green, framed with tall mountains, dotted with cattle, and pray that I will never forget that night.

                                                           -A physician

 

Submitted September 5, 2017

The Inner Environment

For physicians who go through a period of dissatisfaction (or worse) with their work, there is a tendency to blame external factors. This is encouraged by countless articles and books written about physician burnout in recent years. It is hard to ignore the factors that seem to conspire against us. The systems we work in that sometimes appear to be as concerned with production as with quality, the avalanche of regulatory requirements, and the disproportionate amount of time we spend with EMRs and wrestling with insurers. All of these things, and many others, take us away from the one thing that physicians value most in reflective moments – unpressured time to have meaningful, human interaction with their patients. True as this might be, at some point we may have to realize that while there are “systems” problems in our work that we cannot control, what we can control is how we react to these potentially destructive forces, and in doing so, we just might preserve a sense of joy and meaning in our work. Controlling how we respond takes hard work, perhaps the hardest kind. It requires that we look inward. 

Ronald Epstein, author of Attending: Medicine, Mindfulness and Humanity, and our 2017 TCMS Foundation Lecturer, speaks of this in his book: “Burned-out physicians are not only alienated from patients; they are also alienated from themselves…. But changing the health care system won’t solve it all. It is important to recognize that burnout has affected clinicians for centuries, and important causes of burnout reside within clinicians themselves. For the first time in memory…some doctors are finally paying attention to their inner environment in a systematic way and finding ways to bring greater presence and resilience to the practice of medicine.”

Paying attention to what Dr. Epstein describes as the “inner environment” is a unique process, requiring skills, patience and self-examination that does not come naturally to most of us, but the rewards for us and our patients can be immense. It is work that leads to the meaning and connection in our daily lives that we always assumed awaited us when we put on that first white coat. 

                                                    -A PWP committee member 

 

Submitted: July 20, 2017

During the past year I have been a part of a couple of physician wellness workshops in which one of the speakers uses an exercise about our calling to be physicians as an ice breaker.  She asks members of the audience to turn to one or two people sitting next to them, preferably someone they do not know well, and tell the story of how you decided to become a doctor.  It is a little awkward telling someone you don’t know something about you that is potentially either a fairly personal story, or one that might just sound lame, or a story you can’t fully put into words.  Over the years, patients have asked me often enough why I wanted to be a doctor and I reply with something very brief and unrevealing−more of a sound bite than a real explanation.  But with a colleague, and in this type of setting, I have found that it does make me think more carefully, to recall complex feeling and events that led to the decision, and then share it with a relative stranger.  It does create an instant bond of sorts, perhaps even a new friend, something that is clearly part of the exercise.  There is also great power recalling and verbalizing the nature of that call all these years later.

 

The second part of the exercise is then to address the question, “Why do you continue to practice medicine today?”  If the second answer is different from the first, and it often is, that is certainly food for thought.  Is the sense of calling to medicine at our current stage of life one that energizes us, fills our work with meaning, our lives with joy even in the face of challenge, or is it now a life of perceived drudgery and annoying obstacles?  The answer may say much about how we interact with patients and loved ones, and whether strategies for change/renewal are needed.  

Considering the need for a course correction might start with a challenge described by author David Whyte:  “…try to imagine what that dreaming young self would think of the strange adult we have become.

                                                      -A late career internist