People Don’t Walk on Their X-rays
In my residency program, post-op X-rays were often used to evaluate the care delivered to patients. Decision-making, procedural, and surgical abilities were judged based on the accuracy of reduction and fixation. (Direct observation was also done).
When care happened at night, this assessment was done the following morning, usually by others who were home sleeping in the middle of the night. The residents used to have a saying that “If you weren’t there, you can’t criticize”. But it was said mostly in sotto voce outside of attendings’ earshot.
There was a lot of stress about whether the X-rays would be perceived as “good enough” by others. Were they “perfect” enough?
Once I started practice, these standards continued to be ones I tended to use to evaluate myself. One day I was discussing this with an older surgeon and he said one of the most constructive (and ultimately kindest) things another surgeon ever said to me. “People don’t walk on their X-rays.”
The truth of that statement helped change how hypercritical I was about the quality of my work by reminding me that a good outcome isn’t only about what can be objectively seen and measured.
It’s not that X-rays aren’t important, because the structure and alignment of the bones are critical for normal function. However, it doesn’t tell the complete story of how someone will do, because it doesn’t show the soft tissues. It’s the soft tissues that so often determine how the person’s quality of life will be. And what their functional ability is going to be.
The same is true in life. The structure of someone’s life, and the visible external things are important. But they don’t adequately tell you about a person’s internal experience. It doesn’t tell you about what hardships they’ve endured or still struggle with. It doesn’t tell you about the thoughts they think, or the feelings they feel. That’s what genuinely determines the quality of their lived experience. Their soft tissue. On the interior.
Because structure is more objective and visible, it is often the first thing we assess. But, just because something looks “perfect” doesn’t mean it is. Structure is measurable and can be a marker for function. But it doesn’t measure function. And ultimately it’s function, how well all the pieces fit and work together, that determines the quality of life and overall sense of satisfaction.
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More Musings
Recently, I read a post by another physician online about an experience he had decades ago, soon after he first became an attending in the ER. The experience still troubled him significantly.
The anecdote was one of so many in a long career on the front lines of healthcare, where life and death are often part of the daily events, amidst the otherwise mundane and ordinary.
Last week I drove to my favorite trails in Point Defiance Park. The roads seemed oddly empty and quiet, even for “the time between the years” as I’ve heard it called. Perhaps I hadn’t noticed it before, since in medicine it’s always been just another week when most people don’t work, but we always had a full schedule.
The day was overcast, as it so often is during winter in the PNW. The trails seemed unusually quiet and dark as well, with fog surrounding the woods and blanketing the Sound.
I was asked recently to give a talk on leadership at a pre-meeting before the annual conference of the Orthopedic Trauma Association. A friend, also both an orthopedic surgeon and coach, is putting on this half-day symposium. I was, of course, honored to be asked and saw it as a great opportunity to do some networking, gain a new audience, and also get more experience in public speaking.
This year I have become reacquainted with grief. Grief is not anyone’s idea of a desired companion. And yet, to be alive, to be in the world, to love, is to inevitably invite grief into your life. Grief is an interesting emotion. Unlike some which blaze and extinguish, grief rolls in and out like the tide, catching you off guard when you take your eye off it, it can slap you to the shore when a rogue wave hits you, unsuspecting and unprepared.
Toward the conclusion of medical school, an oath is usually taken by the graduates–a symbolic commitment to their calling and a promise to guide their medical careers. For years I had the impression that everyone either took the Hippocratic Oath or the Oath of Maimonides. However, in researching this blog I learned there are many more options and came upon some interesting statistics. Until recently, about half of medical graduates took some version of the Hippocratic Oath, with the other half adopting the Declaration of Geneva, the Oath of Maimonides, and various others.
Summer marked the start of medical school, with July being when clinical rotations commenced in the third year and when the transition to the fourth year occurred. July was when internship began, followed by each new year of residency. Fellowships began later but still in the summer. Each year brought advancement and a new role commenced, finally culminating in graduation to being an attending. An independent practitioner. Free to practice medicine out in the real world. With each advancement, I found myself thinking, “I’m not ready for this. And yet, I can’t imagine what would have prepared me further.” This makes me wonder, did I receive informed consent for medical education and training? Did you?
Doctors have been conditioned since childhood to experience not knowing information as a trigger. Daily messages telling you you're not doing it right bring back memories of implied or overt criticism from school and training. There are steps you can take to minimize this effect.
There have been changes to how residents are taught, with the hours they work. There has traditionally been a lot of pushback to this.
The unhealthy pushback goes like this: “I was trained that way. I’m fine. I survived, they can survive too!”
The healthier pushback also has concerns: “If they work fewer hours, they’ll see less patient care, participate in fewer surgeries, and not see the same evolution of a patient’s condition, following the clinical course from beginning to end. This could hurt their eventual knowledge base and clinical acumen.”
I recently read a story written by a friend and business coach about a time when she volunteered at an event. During the event, she had given away all her food to support others. Now she was hungry and the event was still going on. Instead of being praised (as she had expected) by one of the more senior volunteers, she was told “If you don’t take care of yourself you can become an emergency someone else needs to tend to.”
That’s what has happened to our healthcare system.
It’s become an emergency that someone else has to tend to.
“Until I know you better, I will be telling you how to breathe!”
It’s my first day at the Pediatric Orthopedic Hand Specialty Clinic on my peds rotation in my third year of residency.
I have just been barked at by the Professor Emeritus, a retired Army colonel, who runs the service.
When I have clients going through a transition out of clinical practice, they often say things like “Who am I if I’m not a doctor?” There can be a lot of angst created by this thought. (And this is also true for people leaving whatever job they have been doing for a while–it’s not a thought exclusive to doctors.)
Acceptance means taking stock of the situation and not fighting it. Instead of judging it or having a strong emotional reaction to it, take a deep breath. Stop arguing with yourself or others about how it “should” be. You can easily argue that you’re right about how it should be. But being right won’t really help you. It just keeps you stuck fighting an illusion. How it “should” be is a distraction. It is different from the reality you are actually facing.
What if I told you there was a medicine that would improve your wellbeing, productivity, and creativity while decreasing your risks of heart disease, stroke, and chronic illnesses caused by stress?Because that medicine exists. It’s called vacation. It’s not exactly free, but the money you spend on it is well worth it for your longevity in work and in life.
You already know how to round on patients. Now you need to learn how to round on yourself. Self awareness is critical to your health and effectiveness as a physician. Your physical, emotional and mental health.
One of the biggest lessons I’ve learned about perfectionism is that done is better than perfect. In my medical school and residency, we learned about “The Enemy”, a shortened version of “The enemy of good is better.” This is a well-known aphorism that originated in the 1700s and not in medicine.
Perfectionism seems to help physicians succeed in school and in training. Chasing perfection appears to be the acceptable standard during that time. But after we arrive at our intended destination–medical practice–it can make our life miserable if we continue to adhere to it. Not just work life. All life. It is no way to create a happy life because it adversely affects our relationships, both with ourselves and with others.
World events have me thinking about boundaries. Boundaries are created over time and they often change for a variety of reasons. So too are our human boundaries. Physicians need boundaries as well to function at their best. We can mean the physical boundaries of our skin or the cell’s boundaries of membranes. Or we mean the psychological or social boundaries that we live with, and sometimes without. These boundaries can protect us from burnout and enhance our sense of well-being.
Recently I’ve been sharing some coaching tools that can help doctors experience more of what they want in life and less of what they don’t. But just like in medicine, it’s not enough to memorize facts or steps in a procedure. Practice is necessary to really make progress.
Since I’ve retired from practicing medicine, people ask if I miss surgery. It’s certainly been a big life adjustment. But what I’ve realized is that while I’m no longer doing physical surgery, I now do a kind of thought surgery in my new career as a coach.
Many people who work in healthcare were burned out even before Covid made it so much worse. Guilt and shame arise when we judge ourselves for the things we think and feel. It’s important to differentiate between guilt and shame. Let's delve into the differences, and why they matter in solving burnout and cultivating calm for physicians.