EP 27: Is It Burnout or Moral Injury?

Episode Description:
In this week’s episode, we have an in-depth conversation with Dr. Jeffery Smith, an orthopedic traumatologist and surgeon coach, on the topics of burnout and moral injury. We discuss what exactly the terms burnout, moral injury, physician distress, and mental distress mean and explore how the current healthcare system contributes to these issues. We also explore how a focus on wellness can help battle burnout and moral injury.

Connect with our guest, Dr. Jeffery Smith:
Email: jeff@surgeonmasters.com
Website: https://surgeonmasters.com/

Transcript:
[00:00:00] Dr. JB: Ever wished for a safe place to have conversations that need to be had? A place where you could say the things that need to be said? Well, welcome to Hope4Med.

[00:00:15] Hi everyone, welcome back to the Hope4Med podcast with me, Dr. JB. Today we have a fantastic guest. His name is Dr. Jeffrey Smith. He is a practicing orthopedic traumatologist and a surgeon coach. Welcome, Dr. Smith.

[00:00:34] Dr. Smith: Thank you so much for inviting me Dr. JB.

[00:00:37] Dr. JB: So I’m so happy that you’re able to take out some time from your busy schedule to be here with us and talk a little bit about your life and your experiences.

[00:00:45] Dr. Smith: Absolutely. It is a fairly busy schedule and it’s still busy, but I have the opportunity that the last several weeks I’ve been recovering from back surgery. So I have an even more open schedule than I’m used to.

[00:00:59] Dr. JB: What are you doing with all this extra free time?

[00:01:01] Dr. Smith: A lot of thinking, a lot of additional planning, more coaching and trying to tap into the creative part of me that I really enjoy.

[00:01:12] Dr. JB: So, Dr. Smith, can you tell my listeners a little bit about yourself and what made you decide medicine and then orthopedic surgery?

[00:01:24] Dr. Smith: That’s a really interesting story. I mean, I do look back and I was one of these people that as a very young kid I thought of being a doctor and then really, and I would say as early as middle school, I think I had exposure to it through others in the family being exposed to medicine, and so I was indirectly exposed to it and I think I contemplated other careers, but none of them attracted me as much as medicine. And so I was really in pursuit of medicine from a pretty young age. And in medical school, I kept a really open mind, I think that in some ways hurt me because I didn’t narrow down what kind of doctor I wanted to be. But as I was getting into my clinical years, surgery attracted me a lot and as you could appreciate, emergency medicine attracted me a lot. And then I just started, it was more of a go with the flow situation where I then thought about orthopedic surgery, neurosurgery, general surgery, and carefully evolved into, I ended up really following through on just the general surgery interviews and orthopedic surgery interviews. And I had fewer of those, so I prioritized the orthopedic surgery interviews, and then I just didn’t really follow through with general surgery. When I looked into my internship year and my first year in orthopedics I was like, wow, of course this is what I want to do. So I don’t know how that all transpired, but that’s kind of a description of it.

[00:03:02] Dr. JB: Wow. And so when you mentioned that you had some indirect exposure to medicine starting from a young age, was it your immediate family, like your parents that were in the medical field?

[00:03:12] Dr. Smith: They weren’t in the medical field. So, I actually had very few in the medical field, but just were getting cared for. And as a family member, I noticed the care. I mean, I think I was scared of my family doctor, but very impressed with what he did, as a young kid. When I got into high school, I had my own orthopedic injuries and was really impressed with my orthopedic surgeon and just his personality and what he got to do. I mean, I had one, my first surgery was a knee scope and I remember being fascinated by the whole thing. This was in a day when you got admitted the night before the surgery and I had an ACL injury and I got my knee scoped, and, I asked them, hey, can you wait to the very last second to put me to sleep? So I remember them prepping my leg when I was finally drifting off. And to me, it was for some reason, it just was so cool. So it was those exposures that it just kind of kept reinforcing that interest.

[00:04:08] Dr. JB: Wow. Okay. So then we go back to, or jump forward to you finished medical school. Now you’re in residency and you realized, ” oh, I love this.” So, was residency what you thought it was going to be?

[00:04:22] Dr. Smith: Probably not. I think we each picture some aspects of it. I often tell, would tell medical students or residents or people along the way when I was involved in a lot of mentoring was you always find out most about a decision you make a year after the decision you make. And you just have to, prior to that, go with the best available information that you have. So some things were expected and similar to what I had hoped and expected, and a lot was different cause you really experienced the highs and lows. And that– or the phrase that I used earlier where I said, “wow, of course, this is what I want to do,” was really a combination of that high and low crossing paths. And it was just on a shift where we were working so hard, we were working late into the night and I was in the operating room doing orthopedic surgery in some element of early physical exhaustion, and I just realized how much I enjoyed what I was doing, even in that situation.

[00:05:27] Certainly other times throughout residency, those didn’t always coincide. There was great points, things that where the experience was super enjoyable, high learning, kind of everything you dreamed of. And then there was times where it was struggle and hard and tedious and not enjoyable. And I think that, I don’t think you anticipate how many of those ups and downs you have. I think I was fortunate that through most of that, for me, I had a pretty high sense of purpose or drive or goal to achieve, and so it worked out. At that time, nobody, well, let me put it this way. I don’t think too many people were measuring burnout. I do remember once in medical school, that there was a little inkling of that kind of study going on, but very little was known about it at that time. So I don’t think any of us really attributed that to this experience of what we now understand is burnout, moral injury , even physician distress or mental distress that our personalities bring into the experience or our own genetic background or own upbringing, and just that uniqueness about us. And I don’t think we, I think I have a tremendous greater appreciation for that now. And I didn’t even have that much appreciation for that in my first 10 to 15 years in practice, but I had some inklings of it. Whereas like, I just don’t understand why we don’t provide some attention to this for everyone, ’cause clearly I can’t be the only one experiencing this.

[00:07:03] Dr. JB: That’s true. And so, you listed out a few terminologies that I’d like us to delve into a little bit more, in terms of distinguishing between burnout versus moral injury versus mental distress. Can you elaborate a little bit and explain your distinctions?

[00:07:21] Dr. Smith: Yeah, I mean, I think over the last couple of years there’s been a bit of a debate of what we should be calling these things, or that it’s somehow the exact same issue. And so physicians in general haven’t really liked the term burnout because it is suggested or implied that you as the individual are burning out because of a personal failure or personal inadequacy. And as I have spent a lot of time following this, researching it, I just don’t see that as the failing. And a lot of the proponents of the terminology burnout also don’t see that as an individual failure, but that doesn’t mean that isn’t what comes across to those. So, that’s a little bit where some of the controversy comes in and a few years back when Wendy Dean and Simon Talbot, and I think others in her network, published an article about moral injury and it got a very popular response in acknowledging yeah, that’s really what it is, we’re misdescribing it. And I think they pointed out that moral injury, or a quote from one of their articles “Reframing Clinician Distress, Moral Injury, Not Burnout,” they said that moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses deeply held moral beliefs. And in the healthcare context, that deeply held more belief is the oath each of us took when embarking on our paths as healthcare providers, put the needs of the patient first. And that certainly is one of the things that people are experiencing, but burnout is also a well-defined and very highly researched quote, ” conditioner situation,” and it’s described as that. And that comes a lot from Maslach, but she wasn’t, I don’t think she was the person who even coined the term. She just popularized the Maslach burnout inventory and that’s been one of the widest used, there’s a lot others. And they kind of collectively looked at a psychological syndrome that was a response to chronic interpersonal stressors on the job. And they’ve had follow-up articles that highlight that they really have, all along, tried to emphasize the organizational drivers, and it’s really when people misrepresent their research that some have applied it in a fashion that it’s the individual and that it should be sort of in a way taken out on the individual physician, like “you’re burning out, so we need to deal with you,” instead of ” you’re burning out, what is it in our system or in healthcare that’s burning you out?” So I think these are the healthy parts of the debate. And I’d go on and on, ’cause I think this is so interesting, but it has other facets and I think we’re describing slightly different but correlated issues.

[00:10:18] Dr. JB: Yeah. I agree with you. I did a podcast that talks about burnout and moral injury and I am not of the belief that burnout is a personal issue. Resiliency on the other hand is more personal in my opinion than burnout. Hence why I also take issue with the word– well, why I take issue with resiliency, I do not take issue with burnout. And–

[00:10:41] Dr. Smith: Even, even resiliency has an– pardon my interruption– but even resilience really depends on the reader or listener and who’s delivering the message. And in a way I’ve been conditioned to respond to certain words in a positive or a negative way. And I think each of us has a way that we’ve been conditioned to respond to that, but also from experiences of how it applies. And so, if I was your ally and I was working with you to do something, coaching or do a training of other physicians, and we felt that we were allied and I was using the term resiliency, you probably would be more inclined to interpret that as a positive, where if I have an administrator or I have someone who’s putting their thumb down on me and using it as a negative connotation, then I’m not going to interpret that the same way and I’m not going to even respond to it very well. You and I would probably both agree that physicians are incredibly resilient, incredibly. I mean, you don’t get to this point unless you’re incredibly resilient.

[00:11:47] Dr. JB: Exactly.

[00:11:48] Dr. Smith: I kind of twist it and say, what’s the challenge is, is that we haven’t really been trained as well in positive resiliency, it’s emphasized in negative resiliency. So what can you endure? What bad experiences can you endure and then get through it and then if you make it through it, okay, somehow you’re a better physician. I think that if it’s too negatively driven, you actually– that’s not sustainable because eventually the system beats you down, if that’s the only way you look at things. What do you think?

[00:12:21] Dr. JB: Yeah. I mean, I’m curious to listen to an example of using resiliency among colleagues that is different than admin. I agree with you, we are conditioned to respond to different words differently. And I tend to view myself as a relatively open-minded person, but resiliency just rubs me very wrong. And I think, well, I agree with what you said in terms of our resiliency as healthcare professionals, as physicians, there were so many things we’ve had to go through to get to where we are. So many hoops, so many times that we fallen, so many different situations where we were discouraged and yet we persevered and we made it to the other end and we’re still here. And so, too often, the term resiliency is used so that we don’t look at the bigger picture and we don’t look at the system in which we find ourselves in. And that we think that somehow if we provide tools to our healthcare professionals to make them more resilient then things are going to get better.

[00:13:21] Dr. Smith: Right. And I agree with that, but that’s a huge part of the problem is that somehow we need to be more resilient. In fact, you and I both agreed that that’s not the issue. We’re plenty resilient. If the system keeps piling on, you can be incredibly resilient and it doesn’t mean that you want to stay there for the pile on. I mean, this is– I would say, and perhaps you’re an incredible example as well, I think I’m proving it in the last five, ten years when I’ve been very self-aware of this, doesn’t mean I’m perfectly self-aware, I’m just improving my self-awareness, right? But I’ve become– I think I was resilient before, I’ve put a tremendous amount of personal effort into my own resiliency and even included positive resiliency, but if I continue in my work environment, the places where I work and the system in the geographical area that I live is not leading the way in focusing on the healthcare professionals experience, they’re paying attention to value, quality, and the patient experience. Although I think, they may be putting a little bit too much emphasis on one portion of that one or two portions of that pie, but they’re putting almost no effort into our experience.

[00:14:38] And I think you and I would agree that our experience, if we’re really enjoying what we’re doing and fulfilled and whatever it is that an individual physician is seeking to experience in their career, and there’s a lot of really positive things, that should be something we should be reinforcing. I don’t practice in that environment. So I have to be more resilient because I don’t practice in that environment. And I would say 80 to 90% of the country doesn’t practice in that environment. So our resiliency is not enough. But I couldn’t survive in this system if I wasn’t resilient.

[00:15:12] Dr. JB: Yes, but you were already resilient when you got into the system. And yes, I think that there’s a place to have structured resiliency Information and trainings. When we think about like mindfulness and different things like that, I think that those things could potentially be incorporated earlier on, when you’re still jumping through these hoops maybe to allow you to more easily manage all these things that you’re jumping through, maybe incorporating it into medical school. Residency is tough, but medical school, training and having like structured classes and practices about these different tools that you’ll use throughout your whole entire life. I think that might actually be the ideal place to really emphasize it, where it won’t necessarily be seen so negatively. Cause you’re learning, you’re learning all sorts of stuff. And oh, by the way, here are some, quote unquote, “soft science skills” that will actually serve you throughout your whole entire career, and we’re going to have a class about these different tools. We’re going to introduce them to you and you can pick and choose what you like, what fits well, but at least you would have been exposed to them. So that’s my argument.

[00:16:18] Dr. Smith: Absolutely agree. And the best time for most of these things is planting the seed as early as possible, and then growing that seed. And so if that’s in medical school, fantastic, if that’s in other parts of the training, fantastic. Doesn’t mean that are the end all, be all, but they’re very important. I think they’re skills that all of us can learn late, but again, what the organization and the system keep– and I do kind of apologize to some of those people, some of them are well intentioned and some of them are actually successful at it, but there’s a tremendous number of them that just don’t get it. And they really think it’s about us in the positions, and it’s really about how unsupportive the system is. And I think another example of an overlapping issue is this issue of wellness, and the system doesn’t allow physicians to actually practice wellness for themselves and, again, if we learn that early in medical school or in training that some attention to your own wellness matters and that concept that people now bring up, that put your own oxygen mask on first, is super important. But that wasn’t the message that you and I grew up in, where the patient always came first, regardless of how much it hurt you. That’s, I mean to me, when I say that now and the knowledge I have, that’s such a ridiculous statement. Of course, the patient is incredibly important, but if you’re not taking care or were not taken care of as physicians, we can’t do our best. Or if we can, we’re going to do it for a year or two years and then go do something else. What value is that to invest all that time and energy into getting us so trained and so resilient and so many other things that you need to be a good physician, and then wrongly you going to take advantage of that for a couple of years, when you could have an impact for 20 years, 30 years, or whatever you choose to do, like again, even how long somebody is career should be their choice, not the system’s choice of wearing you down to where you don’t even want to do it anymore, or can’t do it any more.

[00:18:25] Dr. JB: Exactly. But along those lines, when we were being taught that the patient comes first, what were we taught to tell the patients to convince them to take care of themselves?

[00:18:35] Dr. Smith: Yeah. And I don’t think there was a lot of, it was more the knowledge and a little bit, we had some very good examples, but we had a lot of bad examples of just telling them and not guiding them and helping them do a lot of it for themselves. It was a lot, “well, here’s a fix,” but fixes don’t work if they’re temporary and fixes don’t work if they don’t look at the big picture. And I think that was the word that I really liked using before where you really got to look at the big picture.

[00:19:02] Dr. JB: Yeah. But even then though, I remember telling my patients, and even still now, I tell my patients like, “hey, you need to take care of yourself.” Patients that I want to get admitted to the hospital for XYZ complaints, and they’re like, “no, I have to go because I have this loved one I’m responsible for, I need to take care of,” and meanwhile, you can barely breathe. And I’m just like, well, how are you going to take care of that loved one if your health is not optimized.

[00:19:28] Dr. Smith: Yeah, and this is something that we should be learning, is how the– and should the supporting, cause the message just can’t come from one physician, it needs to be coming from the whole system– that patients have to be vested in getting themselves better too. And it can’t be just temporary, like you get a little bit better cause you came to my emergency room and I got you improved. Moving forward, you need to take some measures for yourself. In orthopedic surgery, same thing. Here’s what we can do, but there is a huge element: what you can do to be helping yourself, and your family.

[00:20:04] Dr. JB: Yes. And I agree with that, that’s a whole different conversation of health. So what percentage of the individual’s health is the responsibility of the individual patient and not the healthcare worker? So, if I send you home with XYZ and you come back the next day and you haven’t taken XYZ, like how is that my responsibility? But either way that’s a whole different conversation, but going back to our wellness, just one of the things I was just trying to highlight was we, ever since we were in training, what we would tell our patients is you have to take care of yourself first before you can take care of anybody else. Like you mentioned, put the oxygen mask on your face first, before you can put it on anybody, else’s or you before you can help even your kids. This has been a message that’s been around for a very long time, but for some reason, when it comes to caretakers, that’s not applied to us.

[00:20:55] Dr. Smith: And I completely agree with you. I’m still struggling with why that isn’t obvious and why others don’t seem to get that as well.

[00:21:04] Dr. JB: Because I think sacrifice is glorified, not putting yourself first is glorified in medicine.

[00:21:10] Dr. Smith: That’s one component, absolutely. And that’s true, particularly, well, probably any field, but I see that in surgeon colleagues that people that sacrifice more or the most are glorified until it doesn’t matter anymore. And then they’re expendable. And so somehow that taps into a perpetual thing. I’m pretty optimistic that we’re gonna make that change. An element of pessimism is that we’re going to be forced to make that change because we won’t have enough people to care for others if we don’t. But I am optimistic that we’re more open to change to take away or decrease some of that glorification of sacrifice. And I think there’s an element of dosing, like I can be self-sacrificing when I need, but I don’t have to do that 24/7, and I think that’s the balance that we need to appreciate. And I think we have to appreciate that each individual physician should be encouraged to do that. And I’ve seen some people argue this point, it’s not a common argument, but I think it’s super, super important, is it’s so much comparison. Why do we compare each other? Like why is the level of work and effort that I put in even compared to another physician when nobody knows any of the other stressors or aspects to my life. Or their’s. And there’s so much comparison, so it’s that competition, that comparison. And oh my gosh, does the government and the payers love to, to support that competition. Right?

[00:22:47] Dr. JB: Yes, yes they do!

[00:22:51] Dr. Smith: But they don’t want to support the competition of how well we take care of ourselves, because we could compete in that arena too.

[00:22:58] Dr. JB: How much sleep we get. Who got the most amount of sleep last night?

[00:23:03] Dr. Smith: Yeah. Let’s glorify wellness.

[00:23:06] Dr. JB: I will support that 100%. Let’s glorify wellness. Yes. I think you mentioned that wellness has a potential to be the opposite of burnout.

[00:23:18] Dr. Smith: Yeah. And it’s just like the nuanced difference between burnout, moral injury, physician distress, or just the lack of attention to wellness. So if you really look at it side by side, wellness is not a complete opposite of burnout. It’s just not by definition and by even a few different definitions. But I do think that wellness can be kind of an antidote to burn out that if we integrate wellness, it’s certainly going to either mitigate burnout, it might prevent it for somebody that incorporates it very early, or if I’m in the midst of burnout, then wellness can bringing me out of that. And, and again, I feel that that’s both anecdotally what I’ve experienced and what I experienced with a lot of coaching clients that I have. And I also see that being increasingly supported by the literature, like anything, if we’re going to study this, if we’re going to research what things make a difference, it depends on how well the studies are designed and it depends on how impactful the intervention is. But I think we are demonstrating that there are factors that can either decrease burnout or can– if you look at the consequences of moral injury, well what are the consequences that we don’t desire? Well, we don’t desire having less joy in practice or we don’t desire lots of other things related to that stress, again, that each of us kind of has a different response to that. But we can measure that we might have an impact by having things that manage moral injury when the moral injury can’t be controlled by anybody. Moral injury is just when I’m doing everything I can to help a patient and the outcome’s not what I’ve intended, then to me, that’s a moral injury cause I was there to help and I either didn’t succeed or I contributed to it not turning out well, so it’s a moral injury to me. Then there’s the moral injury of the electronic medical record, which we know is a huge one because I didn’t go into, it’s not in my ethic to fill out a bunch of paperwork, it’s to care for patients and to actively participate in that care. So even that’s a moral injury, but there, the system and how we push how much time a doctor spends on electronic medical record, that’s something the system can control because they’re beating down my neck to say, you got to do this, you got to do that. Well, what if I just paid more attention to the compassion and the relationship with the patient? I think I would have a greater impact. So again, these are the different things that for me, in that scenario, wellness isn’t my exercise, it isn’t my diet, those matter and there’s a lot of other components to wellness, but the wellness to me in that scenario, is having less electronic medical record– trying not to cuss– stuff to deal with.

[00:26:13] Dr. JB: Stuff. Yes, stuff.

[00:26:17] You went through the definition of moral injury and how wellness could be applied there and help tackle that, but if we even go ahead and look at burnout, because I think the way that I described the relationship between moral injury is that every day, you experience some moral distress that leads to moral injury that eventually leads to burnout. And you mentioned earlier in terms of the definition of burnout, and this has to do with your occupation, that’s how it’s defined, so anybody who thinks it’s the individual, it’s not the individual. If you look up the definition of the word burnout, if you look at the who definition of the word burnout, it is about your work environment and there’s these three components. It’s feelings of energy depletion and exhaustion, and I think wellness practices and programs can directly benefit that. When you look at these tools that, focus on wellness, it’s all about taking out time for yourself to re-energize yourself. And so that will tackle, they’ll improve your energy and that will decrease your exhaustion. So that by itself, that’s taken off of the list of things that contribute to burnout. Second one is increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job. So, with these wellness practices, we think about like meditation, all those things where you’re able to really connect with yourself and your mind and how you think, and you can really help affect the way that you approach things mentally. So, wellness, 100% can tackle burnout, and I’m not going to say that it’s going to completely eliminate it, but it can significantly reduce it. And if you incorporate a wellness practice early, like we mentioned earlier in our conversation, then that’s going to have the most benefit in your life, especially if it can become like an ingrained part of your day to day.

[00:28:12] Dr. Smith: Yes. And I really liked the way you shared that and I’m sure you’ve done that multiple times for your audience. I think each of us has a way of describing that, but that’s really good. Being at a point where I’m now 20 plus years into my career, I care tremendously about the people in training, care tremendously about people early in practice, and even mid-career. I obviously have a bit of a bias of not being written off. So, I still try to talk to some of the mid- and late- career people, on a message of it’s never too late. Just because you didn’t train that way, just because you didn’t experience it that way, it’s never too late. And so if you can implement these things at whatever point in time, and the best point is now, you have no control about that it would have been better preventative or would have been better early in your career, ’cause you don’t have control of that. You do have control about whether you implement it now. So, I like to give the folks like that and myself hope that they can lessen burnout if they’re in an extreme amount of burnout from their occupation or from the system or their existing job.

[00:29:22] And those where I don’t think I’ve gone– and it’s hard to know cause I wasn’t measuring it– but just as I reflect back, I used to show a slide when I’d talk about burnout as being kind of that it was a country road that was really rolling up and down. It wasn’t to me like that my burnout experience was a crash and burn, it was really just a rolling. And I still experience that where I noticed, like I go through phases where, I’m a little burned out on X or little burned out on Y, and less about I’m burned out on everything. But when I look back, I was probably in a pretty big dip and it was where I felt isolated. I didn’t feel like others in the system cared. And I looked for alternatives. So, one of the things that I looked for was an exit strategy. I mean, there was other reasons, cause I mentioned about my recent back surgery, but I’ve had neck and back issues for a number of years because of the wear and tear of the job. And I feel that I’m a pretty intelligent person, I was like, well, you can’t keep doing this, you have to have a plan. So my plan was to get into coaching as an exit strategy, but it turned into my stay in strategy because there was a lot in the coach training that really integrated a much more effective learning model. And it correlates more with adult learning theory that really focuses on the individual where they’re at and where they want to be and taking the steps to move forward. And so between integrating some of those things for myself and learning more about those strategies, I’ve been able to apply them in a ton of different areas, but especially in the areas of burnout, wellness, and other sorts of self-improvement but they also can be applied to team improvement, system improvement, and so on. I just, I’ve found in my environment and my situation, I’ve had a tendency for myself to focus on personal, whereas with others where they might be in a more conducive environment, a lot of times, it can be a blend of personal strategies and system strategies.

[00:31:29] Dr. JB: Yeah. I agree with you 100% that yes, we should not ignore those who’ve been in practice for prolonged periods of time and say, “oh, this is of no use to you, you’re not going to benefit from it.” That is not the case at all. All of us can benefit from a wellness practice regardless of where we are in our careers, beginning to end and beyond. Even after we retire, I think a wellness practice is something that should be incorporated for our entire lifetime because it’s useful in other realms of our life, not just work, but again, personal, social, like all of these things, can benefit from a wellness routine.

[00:32:10] Dr. Smith: Absolutely. And you highlight some key components and other aspects. I think the great thing about you and others in this space is we’re helping other physicians get ideas and then to take those ideas and actually start incorporating them. For me, it wasn’t an easy transition, and I think that I may have heard about thoughts or ideas of this before, but it also might’ve been when I was perhaps in one of those deeper dips in burnout, which makes it harder to actually hear the messages, but where I was able to incorporate some of them and use them and help me build one component of paying a little bit more attention to my wellness and then move from there. One of the things that I did is looked at kind of eight areas, I integrated into a methodology that I kind of created my own, but it’s really drawn from a lot of other people’s ideas and principles. And though I call them the eight practices of highly successful surgeons, when I’m talking to a broader audience, I just dropped the term surgeons because they are applicable to a lot of different people, probably everybody. But if you try to tackle all at once, it’s overwhelming. And so for me, I focused on just one of them at a time. And it was interesting, when I looked back, I started looking at a few more of them and then I noticed that I was actually improving in some of the eight that I wasn’t even focusing on. And it’s because they’re so interrelated. If I work on communicating with mutual understanding, that impacts my roles and relationships with others. Or my, what I call attitude resilience, so it’s a bit shifting towards the positive. And when I paid attention to my, my early focus was on my physical wellness because I hadn’t exercised in years. My neck and back were bothering me and I couldn’t exercise in any of the ways that I did when I was younger because I couldn’t handle the impact of jogging, or even getting on a bicycle hurt my back. So for me, it was a very uncomfortable thing, but I went and did yoga. Some people think in my role, like I’m a little too out there and almost promoting yoga, but really it was my own personal unique experience to get the physical exercise. It turned out that it also was the only hour where I really shut out the rest of the world. And I didn’t have my pager and I didn’t– and even then I started off not doing that very well, but it evolved to that.

[00:34:42] So these, and then the yoga time became my mindfulness space. And prior to doing yoga I had done like a handful of mindfulness or meditative type things, and each year or each several months, those things have evolved where now I do a lot more mindfulness, but I couldn’t have had that thrust on me nor could I have had somebody thrust yoga on me 10 years ago. There was suggestions and encouragement, but I had to make that step myself and it worked for me, but it isn’t gonna work for everyone. So each of us kind of has to explore these ideas that you and me have and others are supporting in the wellness space, and try it. Like actually check it out. And I would imagine you have stories of trying something out and it not going so great the first couple of times, but through persistence it started to become something that actually worked really well for you. And so, that’s the tremendous fun that I’m having now, is talking about these things to give people either the ideas or encouragement that it can work and it will work if you put the time and energy. And the other thing about the practice is it highlights the word practice, you have to actually practice. And deliberate practice is a super key component of that, because anything that you just do and you’re not really reflecting on whether it’s helping or benefiting you, and going through what is described as the true deliberate practice cycle, then you might get better at it, but you’re much more likely to get better at something that you deliberately practice.

[00:36:15] And so between those two things of deliberate practice and the benefits for me after getting into coach training, I then started being exposed to a bunch of peer coaches that were also learning the field and getting even professional coaching myself, that the coaching complimented the practice. And I think those are things that, where research is showing that a lot of these things have that impact, that we can make a difference. We can improve our wellness, we can decrease burnout, we can manage moral injuries. There’s a lot of system things that we can do, but there we need a collective voice and we have to build that collective voice.

[00:36:55] Dr. JB: Yes, I completely agree. And along those terms, in terms of deliberate practice, you have to schedule it. Our schedules are so crazy and you literally have to schedule it in your planner, or else it’s not going to happen.

[00:37:09] Dr. Smith: Absolutely. There’s some things I had a little baseline or even a decent baseline skill at, and I got into those pretty well, but the self-care and the putting things on my schedule was not something– everything was my professional schedule. And I learned from others, some just in their public speaking, some of their blogs, that supported some of these ideas or tools to actually put things in your calendar. And I have a calendar now that doesn’t look remotely like my calendar 10 years ago, where it just had my call schedule and some meetings. And it has a ton of personal things, I put in my doctor’s appointments, I put in my things that fall into that category in kind of a color in component of wellbeing calendar, and someday, and I haven’t really thought about this except talking about it with you now, like I want to see that that calendar becomes more of that color with time, as well as the family and personal things that also have a different color. I’d like to see those colors increase and the color that I used for my professional activities decrease, but it’s because I put it in the planner and it creates the opportunity to follow through, just like you follow through with showing up with things that are on your professional planner.

[00:38:22] Dr. JB: Exactly. Exactly.

[00:38:23] Dr. Smith: That’s a super important point. And it’s just that skill is easier said than done, but if you either put your mind to it or you have somebody supporting and encouraging you, or you’re inspired to do that, you’re going to be working towards the right direction. And then you just build on it.

[00:38:41] Dr. JB: You also mentioned about coaching and how you’ve received coaching services, you provide coaching services, and I can understand how coaching helps with your wellbeing, but could you elaborate some how coaching affects your performance?

[00:38:56] Dr. Smith: Well, there’s actually been quite a few studies in the surgical world, particularly driven by intraoperative surgical performance, and I don’t know if it correlates, overlaps with with Atul Gawande is a general surgeon up in the Northeast that wrote the book ” Better” and teased the word about coaching and has used the original vision that he had in that book, was that a surgeon would be in the operating room and then an observer or a more senior surgeon would be kind of making observations and then provide critique. So I think that thought or idea that he isn’t the originator of it either, but then as he popularized it in surgery, has stirred a lot of smart surgeon’s minds and they’ve integrated coaching into educational realm, and they’ve looked at it as a, there’s a coaching model that the Wisconsin Surgical Coaching Program developed where peer surgeons would view each other’s videos of surgery and allow performance improvement in that realm of getting better and better at that surgery. But the cool thing about it is it’s framed around a coaching model. It’s framed around a model where you provide feedback that is not, ” oh, you’re a horrible surgeon,” or “oh, you, why did you even go into surgery in the first place,” which is a lot of what, or and you probably in different fields where you hear those messages, like you can resonate with those messages. Like “why did you become a doctor in the first place?” ‘Cause that’s the kind of critique we got. This model is the positive coaching model that says, ” well, what were you thinking there?” In a sense kind of like what went well and I’m not even sure if that model purports that but, and what could you have done better? And I think that phrasing might even be “what could you have done differently?” Although they emphasize on the better, I think you can even play with that language where you don’t even have to have so much judgment, but there’s, that model is publishing studies where it improves the performance of surgery and they can measure either complication rates going down or they can measure how long surgery takes.

[00:41:04] And again, I don’t know all the parameters, cause I don’t have those studies in front of me right now. People are starting to evaluate how models like that can improve performance and it’s showing it makes a difference. And to me, I do coaching in a broader sense. I coached many clients on intraoperative aspects or debriefing on their surgery, but I don’t think that we need to isolate coaching to the operating room or the, our clinical site. I think we can incorporate coaching to a lot of aspects of the life and career of a physician, and so, it’s often about being able to help the other person be the best version of themselves. It lets them get feedback that’s constructive, not destructive. It’s helping them think out a situation themselves and the coach is really the guide. And so a lot of these models do that, but they mix different methods in our methodologies. And I don’t think one is necessarily better than another, but I think it highlights how valuable coaching can be in it. And like you said, it’s in the wellness space, like there’s studies that have shown that coaching can improve wellbeing, that can be professional coaching. I think there’s the, this surgery model that I described to you and I think there’s other models in medicine of pure coaching, and it’s impacted to a degree by the knowledge and experience and training of the coach, but even a basic knowledge of some of these principles is sometimes all that’s necessary to have an impact on physicians. But also like for your audience, even broadly, all healthcare professionals, nurses, everybody, like that list is so long, right?

[00:42:55] Dr. JB: Yes.

[00:42:59] Dr. Smith: I don’t even want to start naming titles. Like I–

[00:43:03] Dr. JB: Just say healthcare professionals.

[00:43:05] Dr. Smith: Even in my experience in the hospital, like, I really did appreciate the person that came in and cleaned my room, took the garbage out. I appreciated the person that was bringing my meals and passively, like everybody plays a role in that system. And the more they are fulfilled in their career and their job, the more positive impact that has on the patient. To me, that’s more than just logic. Like that’s should be a basic understanding.

[00:43:34] Dr. JB: No, they say happy employees create happy customers.

[00:43:39] Dr. Smith: You know this probably being in the same space, that not all the studies are directly in medicine or directly in an individual subspecialty of medicine, but it’s so easy to correlate that with any job or work being done. Could learn about this in emergency medicine or in the emergency room with all the people, healthcare professionals in the emergency room, that you can make a difference by helping that person have the best experience being that person. Right? And I would bet that a ton of patients have that experience from their physician or their healthcare professional that’s interacting with them is enjoying what they do, that it’s a better experience.

[00:44:27] Dr. JB: Yeah. I completely, completely believe it. And even if your time limit is still the same, somehow you’re really able to connect with them more readily once you’re in a happier space, happier mental space.

[00:44:41] Dr. Smith: Yeah. And we have, like we understand that people have good days, bad days. And sometimes as a patient, they’re not having a good day, and we show compassion for that as best we can. And then, when they’re having a good day, they can have the opportunities to sometimes show that gratitude and connection. I mean, sometimes it’s just the timeline of the experience. They come in through an emergency room, not well, super stressed, and just transition to discharge and feeling better, we often see patients make that flip to coming in stressed or angry or ungrateful, and then leaving the patient experience more thankful, less angry, and showing that gratitude.

[00:45:28] Dr. JB: That’s true. That’s true, dr. Smith. So, we are nearing the end of our time together. And with that, I had a couple questions for you. Number one is if my listener wanted to get in touch with you and learn more about your coaching services, how can they do so?

[00:45:46] Dr. Smith: Well, they can reach me directly by email at Jeff, J E F F, @ surgeonmasters.com, or they can go to surgeonmasters.com. And I do coaching services for non-surgeons, but sometimes the right fit is someone that is different than me and I would help them try to find other context for that. I love trying to help other surgeons, that’s a bit my focus, but the other thing is that there’s people that want to be getting involved in coaching and at Surgeon Masters, we do a physician coach training where the coach trainees are not just surgeons as well. ‘Cause I think having this impact, putting people into this system that are going to be helping others is really gratifying because then you start to broaden how many other peoples that appreciate wellness are working against burnout. But they can reach me with any questions or just to make the connection.

[00:46:41] Dr. JB: Okay. And we will include the link to Dr. Smith’s email and webpage in this podcast description. And finally, Dr. Smith, do you have any parting words of wisdom that you would like to leave with my listener?

[00:46:58] Dr. Smith: Great question. I would really just encourage people that if they want to experience wellness, they need to practice wellness. And if that’s five minutes, if that ‘s an hour, like you don’t have to put a constraint on what you think is expected by the world and the culture and everything else that you do, just start practicing it in one way or another. And take the things that you hear from Dr. JB on her other podcasts with her other guests, and try to implement those things that you think made a connection with you and try to actually practice those.

[00:47:37] Dr. JB: Yeah. Who says a doc can’t rap? D O C T O R J B. The greatest doctor to ever touch the mic. The greatest podcast ever broadcasted or prerecorded. Come learn some. Each one, teach one. I’m done.

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