You may ask “what does mindfulness have to do with resilient leadership?” Believe me, I wondered the same thing but was willing to learn. Before you roll your eyes, just think about for a minute…… if a past SURGEON GENERAL OF THE US ARMY says “Ken, I wish I had more insight and practice at it prior to becoming the Army Surgeon General” you may want to listen.
A few months back, I was thrilled that Dean Taylor, MD sent me an invitation to Annual Feagin Leadership Program at Duke University. The topic on RESILIENCY instantly had grabbed my interest. I wondered what skills these leaders would teach us in strengthening our inner core to tolerate the challenges we face as surgical leaders. On the day of the event, I was not let down as the first speaker was Coach K (Mike Krzyzewski for those who are not Duke fanatics). Coach K discussed the valuable lessons learned as a successful NCAA coach (that editorial awaiting his review).
The next speaker, Dr. Sotile, began to describe the process of BURNOUT and how to resolve this in your own lives. At first I was not too certain of the relationship to resiliency but I listened intently and soon understood the pertinence. (details in http://crisislead.blogspot.com/2016/05/resilience-and-burnout-lessons-from-dr.html). It is certainly no secret that burnout amongst high stress professionals is not uncommon no matter what the profession. That was highlighted in a series of papers stemming from the 2010 American College of Surgeons survey on burnout and addiction in surgeons. At that time, it was uncertain what we should be doing with this information other than acknowledging it. In November 2015, Dimitrios Stefanidis, MD (Carolinas Simulation Center) and I discussed their recent paper ‘What coping strategies are surgeons relying upon during surgery,‘ in the American Journal of Surgery. In their paper we learned that:
1. Half the surgeons report having witnessed intraoperative complications directly related to surgeon stress.
2. Most surgeons believed that stress management training would be beneficial in surgery.
3. Most of the factors that were queried were ranked as very or extremely stressful in 50% of the attending surgeons but not 100%.
Also in 2015, Bernstein and colleagues wrote a paper describing the poor response seen in residents in dealing with catastrophes. It was evident that we have not improved upon training surgeons to handle the stress of a catastrophic event in a more productive manner- as likely we are poor role models to begin with. Yet, in spite of this growing literature on burnout, these reports were deficient in methods for combating stress. With this in mind, I acknowledged that understanding burnout and learning potential methods of managing stress our lives is extremely important to avoid burnout.
On that note, the next speaker was LTG (Ret) Eric B. Schoomaker Surgeon General of The United States Army 2007 to 2011 (prior to that he was the Commander of the N. Atlantic Regional Medical Command and Walter Reed Army MC). With that title I just assumed we would hear how to maintain resiliency while leading large groups of soldiers and physicians during times of duress. Yet something strange happened. For one, he had NO SLIDES. He asked us to stop what we were doing, put our electronics away, put down our pens and papers, put our feet flat on the floor, sit up comfortably, hold our hands in our laps, and close our eyes. We were instructed to only focus on our present--- forget about yesterday or what we had to do later—just focus on our breathing…. My instinct was to see if anyone else was doing this. Everyone was but me, so I closed my eyes and instantly my brain began to wander. The General (obviously reading my mind) said to focus on my breathing so that’s what I did. Sure, my mind tried to wander but soon I heard the HVAC system and absolutely nothing else. Imagine a room full of surgeons, DEAD QUIET! I was amazed at first that we were practicing meditation in a leadership program on resiliency!
I then remembered a conversation I had this Fall with Psychologist Mihaly Csikszentmihalyi (founder and co-director of the Quality of Life Research Center) who has spent his life investigating flow or the "optimal experience" (what makes an experience genuinely satisfying; the state of consciousness called flow). He explained to me that during the writing of his book Beyond Boredom and Anxiety, he interviewed surgeons to see how they continued functioning in a stressful environment but enjoyed their work. He noted that the surgeons he spoke to who were positive about their field, had a knack for being able to simultaneously think of their work as a craft but at the same time be on guard for potential mistakes. The ones capable of focusing positive energy on their success and the enjoyment they had, did well. I remembered conversations I have had with many Military leaders regarding the benefit of “combat breathing”, so it occurred to me that there must be something to this. Lt. Col Dave Grossman (former Ranger, paratrooper and West Point Psychology Staff; Author of On Killing and On Combat) explained to me that he is very keen on using this technique for all situations, including anxious students.
LTG (Ret) Schoomaker went on to consider the art of meditation as a method of building adaptability- the essence of responding to your environment in a positive manner to maintain your strength- like bamboo. As General Schoomaker noted, we spend our time in the present tense, thinking about the past or future, but not actually in the state we currently are in. Those around us pick up on that and feel we are not centering our focus on them when perhaps we should be. So for us to survive we need to learn to live in the moment. Dr. Schoomaker shared with me his commencement speech he gave at Baylor College of Medicine May 31 2016 title “Be Mindful”. In this speech he shared the following take-home messages (abridged with his permission):
“We spend well over 95% of our thinking about the past and the future. …. I consider these past and future realms largely “fictitious” because we know that much or what we reconstruct of the past is our unique and often flawed perspective of the events and, by definition, what we imagine of the future is a fiction for it has not yet occurred……
What our minds do then in dwelling on the past—too often with regret or guilt—and the future—sometimes with fear and catastrophizing—is to keep us from an appreciation of the present moment. Fortunately, we have a sixth sense beyond taste, touch, smell, hearing, and sight that is often overlooked: awareness. …. That same awareness permits you to gently move the thoughts aside to focus on the present—the feeling of the seat against your back, your feet against the floor or your breath in and out. This awareness is the centerpiece of mindfulness and if I can leave you with any take away message today, it is that you aspire to be mindful.
Mindfulness is a skill, a disciplined practice rooted in the neuroscience of how your brain works that improves your working memory and attention. Among other benefits of mindfulness, …. it can be applied to the reduction of stress and … can prevent PTSD in many soldiers. It is the fundamental premise for a prayerful practice, for monastic meditative religious rites, for yoga and for your getting through a stressful test or a demanding patient when you take deep breaths. It does not clear the mind—nothing is capable of doing that. Remember, we are story-tellers. But it permits you to usher all of those wandering thoughts, without judgment or condemnation, into the corners of your mind so you can focus on the present…………
I have observed that what prepares us best for the ambiguity and uncertainty of the science, business and biosocial complexity of our future in health improvement & healthcare is to be grateful, optimistic and full of wonder for the present moments we experience. Those examining the growing physician compassion fatigue and alarming rates of physician burn-out observe that an antidote to these worrisome trends are the skills and habits that come of mindfulness. “
At the conclusion of this talk I had some questions of General Schoomaker and he was very gracious to discuss this with me:
· When did you realize the importance of meditation and mindfulness? He stated that he was juggling multiple priorities as an internist & hematologist, a training program director and later, a commander. At that time he just did not fully understand that the unremitting pace we lead is simply non-sustainable. It was not until he considered that his wife had been using Yoga and imagery 20 years ago that he realized that he could overcome the bias away from being a reductionist scientist and focus on Mindfulness. He had understood that Yoga practitioners were looking at postures that fostered meditation and awareness that was focused on improving mindfullness. He was introduced to Dr. Jon Kabat-Zinn, Ph.D in 2008 who began to open his mind to these concepts. He conceded that “The first time I talked with Jon Kabat-Zinn in 2008, it was really over my head and only in the past several years that I figured it out.” We then discussed a course being conducted over the past ten years intended to prevent burnout and the erosion of compassion in medical students at Georgetown University. He stated that the work of GTU faculty Adi Haramati and Nancy Harazduk he referred to documented a reversal of that erosion and burnout.
· What was the difference in your life after that?
“I wish I had more insight and practice at it prior to becoming the Army Surgeon General”.
· How do you engage experienced busy leaders to discuss and think about this- you know the ones who have seen it all or there are so many priorities and to them, this is not one of them.
“If you are not ready for it and do not have the experience in crises that they helped me through, then people will be resistant.”
“In general I find that at first people are harshly resistant to these methods”, they are very skeptical.
He explained that when a leader opens his/her minds to these methods however, they then discover its benefits. One such success story was an “Army Brigade commander, working for Chief of Staff of the Army, connected to the mindfulness training of Elizabeth Stanley at Georgetown University.” That commander revealed to him that “that was one of the most powerful tools of resilience that he has accomplished as a Ranger officer who had navigated over a dozen combat tours”.
· Can one multitask? Can you really just drop the load off your mind on the spot? Can you drop the prioritized assignment you just incurred? How do you prepare yourself when you need to just drop everything and focus on the moment- the person directly in front of you .
“Multitasking does not exist. We are actually rapidly sequentially tasking, but not really accomplishing several tasks at once.” That is “1 + 1 may not equal 2 but will likely be 1.75. You may not be doing both tasks equally well at all and likely both will suffer.”
“Successful Golfers (and other athletes) are very good at this… they clear their mind of last ball before going on to the next hole”.
He explained that this is not something that works immediately but takes much practice to succeed. We need to learn to “partition time to focus on that moment in time”.
He came to realize this when he would be at lunch with a physician-lawyer friend of his. He said that the “my friend would get a call and tell the person that he was not able to talk and had to come back to that conversation later. He maintained his engagement on the ongoing conversation. I was just amazed at how he could switch off that particular problem so easily.”
· Isn't this counter intuitive to what we tell our kids or junior staff: "get your head out of the clouds, get off your phone! stop living in the moment, think about your future, think about the consequences of what you did in the past". He was very quick to point out that planning and thinking ahead “plays an important role in your future, but planning for the future emanates from the present… you must focus on the present so you can look to the future.” You must learn to be in the present or planning for the future may be inhibited. He recalled a CD series from "The Great Course" by Professor Mark Muesse at Rhodes College in Memphis who told explains that the “essence of mindlessness is when we have a dialogue in our head about the past or future that is playing over the present, much like a film DVD that is stuck on the dialogue option with the director and an actor talking over the soundtrack of the movie”. He reiterated what he learned from Amishi Jha PHD in neuroscience in Miami that “meditation expands your working memory and increases your ability to be attentive”. This is how you can then open your mind to what you will need to do in the future.
· What works for you in increasing your awareness:
· “Exercise! – running, yoga, stationary bike and others help me focus on the moment”
KENNETH A. LIPSHY, MD, FACS
- Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
- Gazoni FM, Amato PE, Malik ZM, Durieu ME. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114(3):596–603.
- Anton N, Montero PN, Howley LD, Brown C, Stefanidis D. What coping strategies are surgeons relying upon during surgery? Am Jnl Surg 2015. 210:846-851.
- Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. JSE 2015.72(6):1179-1184.