Words Matter

That was a crazy game of poker

I lost it all.

O.A.R. That Was A Crazy Game of Poker

In the news this week was a story out of Washington State where a bill was going through the legislature. This bill was designed to address working conditions and ensure that nurses had appropriate breaks during their shifts. As a part of the process an amendment was introduced to exclude critical access hospitals from this bill.

State Senator Maureen Walsh argued for an amendment to exclude these hospitals or to limit nursing shifts to 8 hours per day, but in her argument stated that nurses, “probably play cards for a considerable part of the day.” The CNN report is here.

I am no politician, but I can not understand how someone could possibly think that insulting an entire profession would help sway support for her argument. Nurses are some of the hardest working, devoted people I know. Full disclosure: I married one. Not only that, I was a patient where nurses took care of me when I was in college and seriously sick. I also work with nurses every day in my office, in the operating room, and in the floors of the hospital. They are the front line and keep patients safe. They are often the first ones to identify when something is not right and save patients on a daily basis. Insulting this noble profession is not a good idea.

Take it from someone with experience. Do not make nurses mad. They remember everything!

With our move to Florida a couple of years ago, my job changed from covering just one hospital (in Virginia) to providing care at two hospitals that are about an hour apart. While I rarely have to go to both hospitals at the same time, occasionally I have to go to both places or have to spend some time going to Tampa for meetings. Instead of listening to music, I have gotten into listening to podcasts in my car while I am traveling. I have actually gotten to the point where I can listen to them on double speed and if I listen to them on regular speed, it sounds really slow. By my count, I have 33 different podcasts on my stream. These vary from news, leadership, the Gators, history, and medicine. I thought it might be fun to figure out my top 5. This was not easy to do. At the end of the day, I tried to figure out which podcasts I prioritize when I have a number of them to listen to.

These are in no particular order:

1. The Daily—I have listened to this podcast since it debuted in February 2017. It is a daily podcast produced during the week and hosted by Michael Barbaro. This podcast focuses on a big issue in the news and gets into some detail about it. I personally have found it well balanced and enjoy that at the end of each podcast they have a short, “here’s what else you need to know today.” For me, I feel like I have a pretty good grasp on the big news items of the day if I listen to this show daily.

2. How I Built This—this is an NPR podcast hosted by Guy Raz. I have several podcasts that he hosts on my stream including TED and WOW in the World. This podcast has been fascinating to me as it looks at the stories behind how some of the biggest brands and companies in the world came to be. There have been episodes on Stitch Fix, Southwest Airlines, Jet blue, Angie’s List, FUBU, to name a few. The podcast always features a version of Guy Raz asking if the interviewee thinks their success is luck or hard work and most will tell you it’s a combination. Finally, every episode features a listener and what they are building and some have been amazing.

3. The Jordan Harbinger Show—My wife turned me on to this show when it had another name. The host then went out on his own and the podcast has improved because of it. He likes to talk about many different topics and interview many different types of people. There are a lot of episodes on networking and how to improve ones life, but I think trying to lump this podcast into self help does it a disservice. It’s really trying to figure out how successful people function and providing a practical application to the listener.

4. The Dooley Noted Podcast—I enjoy this podcast for my Florida Gator fix. I personally like this one because it is a broad overview of most of gator athletics and includes all sports, but is driven primarily by football. I enjoy reading Pat Dooley’s columns so it’s no wonder that I like to listen to his podcast as well. He often has great guests and can provide some insider information from his time covering the programs. He is very knowledgeable and I enjoy this podcast because I get a broad overview—if I want to relive a football game and figure out why Florida won or lost, I listen to the The Gator Nation Football Podcast as they go in-depth after every football game with X’s and O’s.

5. Revisionist History—Malcom Gladwell’s podcast about history. He likes to reframe historical events that we think we understand and go into detail and show us that we don’t really understand the events quite as well as we thought. I enjoy this podcast because he is a good storyteller and I personally enjoy his takes on certain events. One of my favorite episodes was from the first season and it was about Wilt Chamberlain. It focused on how he was such a great basketball player except for free throw shooting. However, for a period of time he shot his free throws underhanded similar to how Rick Barry shot his free throw shots (Rick Barry’s son Canyon Barry played for UF and shot the exact same way). With this new technique he had more success shooting free throws and had a 100 point game, but then changed back to shooting overhand. Malcom Gladwell discusses why this might be the case.

Those are my top five. Sadly, like books, there are more podcasts to listen too than I have time to do it—but if you have one I should listen to hit me up on twitter @jpwilsonmd

Last year when I attended the 2018 American College of Surgeons Leadership & Advocacy Summit, I made plans to attend in 2019 as it is such a high yield meeting. I arrived on Friday for the General Surgery Coding and Reimbursement Committee meeting which took place Friday afternoon and Saturday morning. The didactic leadership component kicked off on Sunday.

The meeting kicked off with a panel session by surgeons who are working in the C-Suite (the location where the CMO, CEO, CFO work). The session included Dr. Michael Zinner who discussed the gradual advancement of his career leading up to the C-Suite similar to graduated levels of responsibility in surgical residency. Second, Dr. Douglas Slakey discussed how it is important to know how you want to be defined. Do you want to be a surgeon or an administrator? He also noted it is important to have a vision and find ways to motivate teams to get there.

The third panelist was Dr. Carlos Pellegrini (a past-president of the ACS) who discussed how important character is in getting offered leadership positions and advocated for pragmatic optimism. People do not want a complainer leading them but want someone who is grateful. Finally, Dr. Julie Freischlag discussed how surgeons make decisions in the C-Suite. Surgeons tend to make quick decisions, but patience is important.

As a group they noted how important this meeting is for learning leadership skills.

Some important themes:

1. You have to be able to lead teams and keep people on the same page
2. When you reach leadership roles you have to empower people and delegate.
3. You have to be flexible and know when things are not working.

This was followed by an excellent panel discussion by Mr. Gary Peck who is the executive coach for Dr. Patricia Turner of the ACS. He noted how important it is to have engaged employees. Engaged employees lead to satisfaction, loyalty and ultimately growth. In addition, it is important to have situational leadership because every situation is different. Finally, he noted that a study shows positivity leads to superior productivity, more resilience, less burnout and less turnover.

Dr. Thomas Mason, CMO of the Office of the National Coordinator of the National Coordinator for Health Information Technology gave the next presentation. He reviewed the landmark health legislation of the last 10 years which led to our current electronic health record. He notes their focus is currently on interoperability and decreasing burdens of physicians. This is so important. In 2019, we are a profession with robots and lasers and we rely on CD-ROMs, faxes, and a stack of paperwork to see patients.

We then moved into Chapter success stories where we heard from three chapters.

1. Dr. Paula Ferrada and how they engaged young physicians in Virginia
2. Dr. Jason Weinberger who discussed how they developed an ABSITE course in Delaware.
3. Dr. Bradford Barrett who discussed how they used Stop The Bleed and are well into legislation on the matter in Indiana. The Stop the Bleed program is designed to help bystandards help in the case where someone has suffered a life threatening bleeding event.

During our breakout sessions we met as Florida Chapters and were able to discuss how the Florida Chapter could increase advocacy and educational efforts between the chapters and to engage surgeons in the state of Florida.

After coming back together, Dr. Dana Telem spoke about Mentorship and how Mentorship should be bidirectional and help you build skills. The University of Michigan has done a lot of work on this issue and are having a Mentorship Course this summer. She provided some great slides on Mentorship from the work done in the area and are worth reviewing when available on the FACS webpage.

Dr. James Elsey who is Vice-Chair of the Board of Regents gave a presentation on leadership and how surgeons need to be involved in healthcare policy and leadership. He noted that people follow your why and not your what. People care about what you believe in and this is the catalyst for change.

We then moved on to Dr. Fernando Lamounier who presented on negotiating. He notes we are always negotiating and as the father of a four year old, I can tell you I negotiate constantly with him. I’ve mentioned previously he would make a good lawyer, so I’ve learned a lot about negotiating with him. Dr. Lamounier notes the biggest worries about negotiating are a lack of confidence, worry about looking bad, and difficulty determining self worth. He provided an excellent overview of contracts and negotiating.

The last presentation was by the Executive Director of the ACS, Dr. David Hoyt. He provided updates on the College and where it is going. In particular he noted the College is trying to stay true to the motto, To Serve All with Skill and Fidelity. The college is doing a lot of great work to represent all of its members. “A surgeon’s leadership is essential because a surgeon’s perspective is essential.”

This was another great meeting. This is one of the highest yield meetings in terms of education and networking. Kudos again to Dr. Turner and the American College of Surgeons for putting on such a great meeting. One of my goals for the day was to make sure I met Dr. Turner and I succeeded!

The 2019 Annual Meeting of the Florida Chapter of the American College of Surgeons (FLACS) took place this weekend March 22nd to 23rd at the Royal Pacific Hotel in Orlando, Florida. The theme of the meeting was Controversies in Surgery. The meeting started on Friday afternoon with the Presidential Lecture. Dr. Stephen Grobmyer returned to Florida from the Cleveland Clinic to given a presentation on the management of the axilla in breast cancer and to highlight some work they have done using fluorescent dye to map the axilla as well as lymphatic venous bypass to help reduce lymphedema in the patients who still require a complete axillary lymph node dissection. For me, it was great to see Dr. Grobmyer. I have not seen him since I was a resident and he is responsible for my first paper and poster presentation at the Southeastern Surgical Congress several years ago.

The second section was a panel session by Drs. Mark Soliman and Steven McCarus as well as by Patricia Toor. They discussed laparoscopy and robotics from the standpoint of the patient, the surgeon, and the health system. It provided an avenue for interesting discussion amongst attendees about this hot topic. I’m not sure we came to a consensus but it was quite enjoyable. While these sessions were going on the residents were doing a Surgical Simulation Session and Surgical Olympics. After these topics we had a social and it was nice to catch up with some friends within the FLACS.

Day two of the meeting started with a panel session regarding Controversies in Community Care. I was honored to be able to moderate this session. I enjoyed the session and am proud to say we stayed on time. There were three debates during this session. The first was Dr. Laronga discussing the use of Targeted Axillary Node dissection for women with breast cancer who had node positive disease convert to clinically node negative following neoadjuvant chemotherapy. Dr. Grobmyer was given the opposite side to debate. This was followed by Dr. John Mullinax and Dr. Vernon Sondak debating completion node dissection for patients with a positive sentinel node in melanoma and our last was a discussion by Dr. Atif Iqbal and Dr. Giovanna da Silva Southwick on what age to start screening colonoscopy and what is the best test.

We then had two very nice sessions on advocacy. First, Dr. Patrick Bailey who is the medical director for Advocacy and Health Policy with the American College of Surgeons and Christian Shalgian who is the director of the Division of Advocacy and Health Policy discussed advocacy within the College and walked through some issues and how they frame Strategic Advocacy. It is not enough to just want something done, you have to think about the issues from multiple angles to decide the best way to get the job done. It was an illuminating look at the process. I am thankful for my opportunities to better understand this process over the past year spending time on the General Surgery Coding and Reimbursement Committee within the American College of Surgeons.

Second, Dr. Gary Timmerman gave the keynote address on regulation and what the ACS has done to try to help relieve the burden of regulation on surgeons. I had quite a nice conversation with him during one of our breaks and it was nice to make a new connection and I am looking forward to seeing him in the future. He spoke of one my treasured mentors both during his talk and with his conversation with me. He spoke of Dr. Ted Copeland, past president of the American College of Surgeons who told Dr. Timmerman that while Dr. Copeland could open doors for him, it was up to Dr. Timmerman to walk through them.

Our last component of the day was dedicated to oral abstract presentations. We heard three very good basic science presentations followed by three clinical science presentations, and finally three Commission on Cancer papers. For the first time we then had case presentations of “Spectacularly Challenging Interactive Case Presentations.” These cases led to some of the most interactive comments of the day and was a successful addition to the program. There is no doubt the future is in good hands with these residents.

On a personal level, I have been excited about friends I have made in the last year within the FLACS. Dr. Armstrong, (the current president of the FLACS) said you should look back to last year and compare this year. I have met so many great people within the chapter over the last year and become much more involved. I was honored to be asked to chair the communications committee over the next year and am looking forward to helping get the word out about what the chapter is doing.

Five hundred twenty-five thousand six hundred minutes

Five hundred twenty-five thousand six hundred so dear

Five hundred twenty-five thousand six hundred minutes

How do you measure, measure a year?

Donny Osmond, Seasons of Love from Rent

My kid he asked me ‘daddy when you coming home to me from work?’

If I’m being honest man that hurt.

O.A.R. I Go Through

There are a lot of important conversations happening around physician burn out and about work-life balance. I have also heard people say that work-life balance is a misnomer because balance implies equality. Equality of time is a standard that almost no one will ever be able to obtain. Using the song from Rent as my starting point my conservative (back of the envelope calculations) are:

525,600 minutes/year

-10,080 minutes a year traveling without my family (7 days in a good year)

-171,360 minutes a year sleeping (51 remaining weeks x 8 hours (if lucky) x 60

-172,800 minutes a year where I am at or traveling to/from work (approximately 60 hours a week x 48 weeks).

Leaves 171,360 minutes per year or roughly 56 hours per week. Some of those minutes my son is asleep and my wife and I have time together. Some of these minutes go to self care including exercise and some go to various projects that need to be done around the house. It is important that my wife and I have time to date to keep our relationship growing.

For me, I have had to quickly realize that what I lack in quantity I need to make up in quality. While I am not perfect, I try to be home when I am home. I try really hard to make sure my family knows when I am home with them I am home. I was excited that I got to take Bradley to school on Thursday for Donuts with Dad. It meant starting my OR a couple of hours late, but it was worth it to be with him for that time.

One of my goals is to make sure that my technology does not become a distraction. I have to be somewhat connected as a physician, but I would like to be able to put my phone away on the weekend and just get it out to catch up at the end of the day.

I am not sure I will ever reach a balance, but I will settle for work-life satisfaction.

Hey son, go to California, live with the angels, love who you wanna

Anyway, you know I’ll miss you, just like your mama, call if you want to

Anytime, you need a hand now, I’ll be there now, just like I taught ya

Anyway, who says you can’t go where you wanna, California

O. A. R. California

Sometimes, physicians have an unusual view of the world. I always remember growing up and loving when we would change from Daylight Savings Time back to standard time in the fall (fall back). I always loved to gain that extra hour and as a teenager it meant an extra hour of sleep. In actuality, normally, I would just stay up an extra hour and not feel bad because I knew I would not loose any sleep. The converse was true as well. I hated the start of Daylight Savings Time because it meant it was time to ‘spring forward’ and I was going to lose an hour of sleep or I would have to go to sleep an hour earlier. Of course, what I did not realize at the time, is that both of these days are meaningless when you have a small child. My son is not sleeping an extra hour when we fall back.

When I started surgical practice and was taking general surgery call we would take call for the hospital for the weekend and would start on Friday morning and it would run until Monday morning at 7:00 am. I quickly realized that if you were on call during the fall back weekend you had an extra hour of call that weekend and that meant an extra hour of taking call for the emergency room. Don’t get me started on how you document something during that hour that happens twice!

However, the opposite was true as well. If you took call on the ‘spring forward’ weekend you had an hour less of emergency room call. That was the weekend I wanted! You would not think that 71 hours vs 72 hours vs 73 hours would be a big deal, but it sure felt that way to me. So while everyone else was sad about losing an hour, I was ecstatic.

Another place where I found I had an unusual world view was also related to call weekends. After spending the 71-73 hours on call for the weekend and the day starting on Monday morning, I can not tell you how many times I was the happiest person in the hospital when Monday morning at 0700 hours arrived. I was no longer taking new consults and I was no longer covering the entire service. I would talk about this often with my surgical assistant Leslie at the scrub sink in the morning. I would be washing my hands for my first elective (or add on) case and while the rest of the staff had the Monday morning blues, I was gleeful that the weekend was over and I knew that when I went home that night, someone else had the call.

If you have other examples of strange ways physicians view the world compared with everyone else–share them with me!

Anyone who has known me for any length of time has probably heard me say, ‘words matter.’ It only makes sense that my blog have the same name. I have been using the phrase ‘words matter’ since medical training. It is critically important in healthcare that we use the correct words to express what we are trying to say to each other. A huge part of medical training in both medical school and residency is learning the medical lexicon. It ha always been important that we are precise in our words.

One of my favorite shows for years has been The Big Bang Theory. Sheldon Cooper, played by Jim Parsons, likes to correct people throughout the show. One of my favorites is his annoyance with the hyperbolic use of the word literally.

Words have meaning. When taking general surgery call, there were always certain words when I heard them in the middle of the night that would instantly snap me awake. Peritonitis (inflammation of the abdomen), pneumoperitoneum (air inside the abdomen), pneumothorax (air outside the lungs), and sepsis (severe infection) were all words that could instantly wake me up. Anytime I heard any of these words, I would immediately need to figure out if the patient needed surgical intervention and required an urgent trip to the hospital to evaluate the patient.

Now that I have a small son, I have found that I need to be even more precise with my words because my four year old has the mind of a seasoned lawyer and is able to find any loophole in my words.

Words are how we communicate and it is important we use the right words. When giving advice about public speaking, we are often told that non-verbal communication is more important than the verbal communication. While I believe that non-verbal communication is important, choosing the right words can be just as important. My hope is that the words in these blogs are right for anyone who reads them.

“I keep a diary in order to enter the wonderful secrets of my life.  If I didn’t write them down I should probably forget all about them.”  Cecily Cardew, The Importance of Being Ernest, by Oscar Wilde.

Why start a blog in 2019?  Aren’t there enough blogs out there?  These are the questions I have asked myself before starting this endeavor.  The truth is this blog is for me more than it is for anyone else.  I enjoy writing. It has not always been this way.  When I was at Lakeland High School and Furman University, I did not enjoy writing.  The reason was never that I did not enjoy the writing–it was the ambiguity of grading that I did not enjoy.

Leonardo Da Vinci said, “there is no certainty in sciences where mathematics cannot be applied.”  This is the reason I was always drawn to math and science.  There was typically an answer (at least in the early courses).  I liked taking tests and knowing if I got the right answer that I would get full credit.

Lately, I have enjoyed writing.  I have enjoyed putting my thoughts down on paper and have been pretty diligent over the past year about keeping a journal.  At first, I was somewhat inspired by Walter Isaacson’s biography of Leonardo Da Vinci who kept so many interesting hand written journals, but I had to quickly abandon the hand written journal in favor of an electronic journal.

In his book, Well-Designed, Jon Kolko, describing strategy says, “if you don’t write it down, there’s little chance that anyone will remember it, believe in it, or act on it.”  I primarily plan to write these posts for myself, but if someone else can learn something, or be inspired from them, why not share them?  I have heard Jordan Harbinger, podcast host of The Jordan Harbinger Show, say that when you start a podcast it should be done as if no one will ever listen to it.  I am taking that approach with my blog as well, but if someone reads it and can get something out of it, then why not?

 

Members of the Woodward Society (graduates of the University of Florida Surgical Residency Program) convened in Gainesville, FL on February 15th for the Woodward Society Spring Meeting. This is our biennial CME meeting. I am the immediate past-president and currently function as the Secretary-Treasurer and as a result had the honor of choosing a lot of the speakers for this meeting. I tried to strive for diversity of training periods and for diversity of topics but due to some unforeseen scheduling changes that needed to be made we wound up with a cancer heavy theme for the day.

We started the day off with a standing room only Grand Rounds presentation by Dr. J. Patrick O’Leary about surgery performed on Grover Cleveland while at sea for a oral cancer. He gave an excellent talk about this and shared some history of the department of surgery as well and in particular some anecdotes regarding the namesake of the Woodward Society.

The chairman of surgery, Dr. Gib Upchurch then updated us on the state of the department. They continue to grow in clinical volume and you can tell from the update the department is heading in a good direction. I have now had the opportunity to speak with him several times including resident graduation last year and at the Clinical Congress in the fall. He has a vision for the department and as a history major has a profound respect for the history of the department of surgery.

We then had updates from three members of the UF faculty on their research. Dr. Jose Trevino gave an update on his pancreatic cancer research, Dr. Ali Zarrinpar gave an update on Liver disease and transplantation, and Dr. Ryan Thomas gave an update on the role of the microbiome in pancreatic cancer.

We then had our Dr. Steve Vogel Lecture Keynote Address on “The Modern Multidisciplinary Management of Colorectal Hepatic Metastases” delivered by Dr. N. Joseph Espat who is the Chief of Surgical Oncology at the Roger Williams Cancer Center. It was a thoughtful look at the progression of surgery for hepatic metastases through the years.

Following lunch we had a talk by Dr. Makesha Miggins about the role of Contralateral Prophylactic Mastectomies in patients who are at average risk. It was a thought provoking talk about risk stratification and patient preferences. We then had one of my long time friends, Dr. Nikki Kissane Lee give a talk on Surgical Simulation. She has helped to develop two separate simulation centers, most recently at Indiana University and provided a roadmap on how to be successful. Our last structured afternoon talk was from Dr. Karen Rieger about the role of Lung Cancer Screening.

One of the highlights was a fascinating discussion led by two of my heroes. Dr. Mike Chen got sick two years ago and had to be admitted to the hospital. He and his wife, Dr. Elizabeth Beierle spoke about the care they received and how we can provide more patient centered care. This is an especially important topic for me as I went into medicine following an illness when I was in college. They focused on how often we do things for the convenience of the physician rather than the comfort of the patient. They provided the examples of overnight vital signs, morning labs, and morning chest radiographs happening so early in the day.

Overall, it was a well attended meeting with some great cancer updates in a program with a strong history of cancer care. It was also great to talk about the role of systems based practice and how this impacts patients.

Following this we had the opportunity to honor Dr. Tim Flynn who is a great in the history of the UF College of Medicine and the Department of Surgery. He retired from the University of Florida recently having been a vascular surgeon, and senior associate dean for clinical affairs. Nationally he has served leadership roles in the American College of Surgeons, the Accreditation Council for Graduate Medical Education, and the Association of Program Directors in Surgery. He had his portrait unveiled for his role as program director and it was nice to have a chance to honor his work locally and nationally.