Becoming A Rockstar Doctor: Part 1

Why Malcolm Gladwell Should Be Required Reading For Medical School

The tidal wave of information thrown at you during medical school can be a challenge to manage and the idea of adding more books to the list may make you want to vomit. But before you do, take a moment to hear me out. 

Besides having a ton of respect for his feral afro, I believe that Malcolm Gladwell is one of the best authors for taking abstract, ill-defined phenomena and clarifying it with surgical precision. His work is some of the most researched writing you will see outside of a PubMed search and that resonates well with evidence based minds.

Throughout our medical training we are taught to question and continually seek to uncover the truth. Gladwell takes that same approach to the subject of success, human decision making, and epidemics with the books Outliers, Blink, and The Tipping Point. I can strongly recommend getting a copy of these books. His insights will give you the tools you need to stand out from the crowd, and make you re- evaluate the way you see your own medical training.

I know you may be busy, even bordering on overwhelmed, right now so I have distilled some of the vital principles into a nice little summary; until you have a chance to take a breath and get the full experience.

Outliers: The Story of Success

At the outset, most would-be doctors become obsessed with outliers, in many ways we all need to be outliers to continue in our career and as we progress this becomes increasingly difficult to achieve.

Opportunity for Quality Learning:

If you where to play hockey in Canada the month of your birth is a major factor that contributes to your success. Outliers explains that the boys who have the earliest birthdays are older at each level of junior hockey. This makes them a little stronger and faster than there peers. Which means they get chosen for the best teams, they get the best coaching, and have the most opportunities for high quality practice.

The point here is not to find out what month is the best month for Rockstar Physicians to be born. It’s the idea that the players selected early are given the best opportunities for learning, practice, and competition. The question then becomes how can I put myself in the path of those types of opportunities in my career.

Understanding the importance of quality learning means that to become an outlier we must be proactive in our medical education.

I do not consider my self an especially impressive outlier but here are three ways I have learned from people who stand out in school and life.

Clarify Your Purpose

What kind of legacy do you want to leave as a doctor, as a person? What do you care about? What would you work on if you had 20 million dollars in a trust fund? These are good questions to help clarify your purpose. The answer, "I just want to be a doctor and help people" is too vague. The more clear you are the better.

It’s important to remember that asking these questions is an important first step. You may not have all the answers right away and the answers may change over time, but the process is important. As you become more clear on your purpose you can increase your focus and place effort into areas of you life that will give you the highest yield.

Seek A Mentor

Good coaching is vital to success. Once you know where you are going it’s much easier to evaluate the type of people who can help you along your way. Asking for advice and help can be difficult, especially in the world of medicine. Many times people hesitate because they think “that doctor is super busy and will never get back to me or will think I am unworthy of their time.”

Yes, both of these things may happen but don’t sweat it, just move on to someone else. However you may be surprised at who will be willing to help you along the way.

Commit To One Small Action Everyday

The road to becoming a doctor is long and it’s easy to feel like you are stuck unable to do anything about some big goal you have in your life because you have no time, no money, and should spend every waking moment trying to care about oxidative deamination in the urea cycle or the blood supply above and below the pectinate line.

Even in the face of all these constrains, commit to one small daily action the brings you closer to that goal. Do you want to start a business, do a super sweet fellowship, or run a marathon? Don’t wait, begin working on that goal in a small way today.

Focused Practice

One of the most striking themes in Outliers is the emphasis on practice. Gladwell shows us why the 10,000 hour rule is important to remember for any would-be outlier. The idea is simple, it takes roughly 10,000 hours, or about 10 years, of focused (the more focused the better) practice to become great at something. He uses examples like Bill Gates, the Beatles, Mozart, and chess grandmasters to make his argument for this 10,000 hour rule.

What does this mean for training physicians and surgeons?

If you do some quick math and estimate the typical resident works 300 days per year (accounting for days off and vacation time). That is about 43 weeks per year and, at 80 hours per week, this means they would reach the 10,000 hour mark in almost exactly 3 years. It’s interesting that this correlates well with the amount of time spent in most of the non-surgical specialties.

But why do the surgeons need five, six, or, in some cases, 8 years? The the answer is focused practice. Gladwell calls it 10,000 hours of “hard practice.” For a surgical resident to reach 10,000 hours of hands-on operating experience it takes much longer. In many institutions the surgical intern and even junior resident spends much of their time outside the operating room and even when the do get to gown up for the OR they often have limited time where they are running the show.

Of course there are good reasons for this, patient safety foremost among them, however this does not mean that we cannot learn from the 10,000 hour rule. Remember just being busy at the hospital does not automatically mean you are becoming a better physician or surgeon. It is important to look for ways to find focused practice and wring the most out of each patient encounter.

This may also mean we need to re-evaluate how we train residents to increase the amount of focused practice they get during training. With arguments surrounding resident work hours, length of training, and the need for increased specialization constantly on the rise, a new look at how residents can reach the 10,000 hour mark as efficiently and safely as possible is important.

Here we have fascinating proof of Thomas Edison’s famous quote:

Genius is one percent inspiration and ninety-nine percent perspiration.

Genius Is Not Everything

Entering the world of medicine means you are stepping into a community filled with brilliant people. We can all think of those people in medical school who had seemly infinite mental horsepower. In some ways we are all in awe of this, we admire it and are, at the same time, a little jealous. But is this the right way to think?

According to Outliers, no.

The book makes a compelling case that genius cannot be soul predictors of success.

Exhibit A: Christopher Langen

Reported to have an IQ of somewhere between 195 and 210 and dubbed by many as the smartest person in America. He is a self taught expert in mathematics, physics, philosophy, Latin and Greek. He got a perfect score on the SAT, even though he took a nap during the test. But he has spent much of his life working as cowboy, construction worker, and a bouncer and has failed to reach his full potential due to his poor social skills and lack of emotional intelligence. (More on this guy at wikipedia)

But Gladwell goes on further, stating that a person's emotional intelligence and likability are often overlooked as measures that many outliers possess.

This idea is especially important to future doctors because our current training system does not reward people with emotional intelligence or likability, only mental prowess. However as attending physicians we are expected to be leaders, managers, and work as part of a team. We have all seen many examples of intelligent doctors who cannot function well as physicians for that reason.

A recent study done by Dr. Andrew Klein a transplant surgeon at Cedars-Sinai Medical Center, Los Angeles, CA. Shows that surgeons who are rude to the operating room staff actually have worse outcomes.

Dr. Klein commented that, "in an increasingly rude society where it is rare for a stranger to give up a bus seat to a senior citizen and expletives have become all-too common in daily conversation, the lack of civility has degraded all aspects of life, even the surgical suite...Operating rooms are social environments where everyone must work together for the patients' benefit. When a surgeon, who is in the position of power, is rude and belittlies the rest of the staff, it affects everything."

Be The Doctor Who Thinks Differently

I can summarize the most successful people I’ve ever known with one trait: the willingness to challenge mainstream ideas.

An Uncommon Guest Post by Leo Babauta

This has been the key to everything good in my life too:

I changed my health and drastically reduced my carbon footprint when I stopped eating like everyone else around me and became vegetarian (and eventually vegan).

I simplified my life when I stopped believing what the majority of people believe, that buying stuff makes you happier, more secure, look better in the eyes of others, etc.

I improved my health and reduced our carbon footprint when I went car-free.

I changed my career by blogging differently than others (on simplifying rather than doing more) when I started Zen Habits.

And there are many more examples, but you get the point. This isn’t a post to brag about all of that — it’s to share what I believe is a real key to life: the willingness to think differently than most people. It means you have to be willing to question what most people do and what the majority will tell you. It means you have to have the courage to try something different. It means you have to be brave enough to stand out from the crowd and not take the safe route.

The Safe Route

Most people take the safe route, because they’re afraid of being different and failing. If you do nothing amazing but you go with the crowd, then you don’t look stupid. But then you miss out on the amazing. If you never stand out from the crowd, you will always be average. True being an average physican is no small achievement but that's not the right way of looking at it. The question should be are you living your dreams are you passionate about your day to day activites? 

The people who stand out are the ones who make a mark, who innovate and discover, who learn the freedom of exploration and invention. If you stand out when you apply for residency or a job, you’ll be more likely to be noticed. If you don’t, and you play it safe, then they’ll likely ignore you. If you stand out when you start a business, people will be curious and check you out. If you’re just one of many businesses doing the same thing, why should others care about you? Why should they choose you?

And yet, most people play it safe:

Most people go to school and then college then because that’s what everyone else does. They don’t know what they really want to do, so why not take the traditional route? And that’s fine, but it’s good to look into other options. Most people get a job and stick to it because that’s the traditional way to make a living. Others might be a solo entrepreneur or start a small business and dare to create something new and live a life they’re passionate about.

Most people eat meat and dairy and eggs because that’s how they were brought up, and eating differently is weird and unthinkable. “I love my ribs too much!” But then you miss out on a whole world of healthy, delicious food, and the opportunity to change the planet and your own health. 

Most people drive a car, because that’s what everyone else does — and changing it is too difficult. And yet, cars pollute and cost a lot and make us less healthy and make the streets less safe for our communities and take up most of our public spaces.

These are just some examples in my life, however the need to play it safe turns up in every part of our lives.

Learning to Think Differently

When you hear an idea that’s different than what you’re used to, pause. Instead of rejecting it outright, consider it — is there some merit? What are the arguments, the evidence? Let go of the emotions that come up, the defensiveness. Many people, when presented with ideas conterary to their belief feel they must lash out and attack. And yet, if you set aside those emotions, and look at the arguments, you might learn to think differently — and that applies to all ideas. Looking at the world, and especially your career as a physican, through these lenses can radically change your outlook.

When you are told that this is the way to do things, take a second look. Is this really the best way? Are there other possibilities? If no one has thought of them, can you? Just because an idea is different, don’t just accept it. Look at the bulk of the evidence, and learn to spot flaws in reasoning.

Test out different ideas.

Just because most people don’t do it, doesn’t mean it’s wrong. They might all be wrong, and this might be better. No better way to find out than to test it. If it’s not a good idea, drop it and move on. Learn to be proud of your ability to test things that people traditionally believe in, and not to worry so much if you stand out. In fact, learn to see standing out as good — not just to stand out, but to forge new ground, to challenge ideas, to express your individual voice rather than blending in.

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Uncommonly Savvy, International Medicine

"Travel is fatal to prejudice, bigotry, and narrow-mindedness...Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.”

-Mark Twain

An Uncommon Guest Post by Bjorn Karlman a Swede with an American accent, an Asian childhood, a British adolescence, French and American tertiary education and international work experience spread across three continents. He speaks four languages and blogs at CultureMutt.com.

The Pain

“I hate that my pay and my whole family’s standard of living is tied to my working crazy hours and then being on call. If I stop doing this day in and day out, we’re screwed.”

“How can I escape my self-made prison?”

“Why did I choose to become a physician?”

“I want out!”

We’ve all heard the above sentiments repeated ad nauseum by physicians. The news gets even worse for medical students. There has never been a bleaker time to graduate from med school. The economy is still in the tank. Reimbursement is dropping and is going to go down further with Obamacare. Physicians all over the country are shuttering in their private clinics and downsizing their homes.

“Hell no!”

I asked a physician friend from Hong Kong who practices in Northern California if he planned on encouraging his kids to become doctors. “Hell no!” he exclaimed without a moment’s hesitation. I work in health care philanthropy and am forever hearing the exasperation of the physicians around me and the gloominess they feel about the future of their profession.

Time to reframe

I really think it is time to look at this whole narrative differently. I am not going to promise hope and change because I am not running for office:) But I do think that it is time for some innovative, international, solution-focused tinkering. It was downright refreshing to poke around in the “About” section of Uncommon Student MD and see that this online medical community is “not interested in the useless hand-wringing that populates so much of medicine and that so many physicians have bought in to.”

Savvy, global do-gooding

I write the blog CultureMutt.com and am obsessed with what I call “savvy, global do-gooding”. I am absolutely convinced that a laser-sharp focus on understanding the culture of various people groups through international travel and service lies at the heart of helping to solve our collective problems. I think it could really benefit the American medical community. A broken culture drives the negativity in American medicine. The future craves a more culturally-savvy, international approach to medicine. I realize that this is a broad statement to make.

Allow me to focus it a little by outlining four ways we can put smiles back on some faces through “global” thinking:

1) International Sleuthing Trips - As much as it is true that America still is home to some of the most advanced medicine in the world, other developed countries often have a far better handle on actual health care delivery. To learn efficiencies and to learn how to do more with less, American medicine should not indulge in further navel gazing. It is time to give more thought to other models of health care internationally. We should aggressively fund more international study trips to examine global best practice in everything from direct treatment to preventative care and lifestyle medicine. The goal here is not some flimsy “experience”. It is to learn how to deliver better health care at less cost.... and travel the world!

2) International Socialization - I remember the day one frustrated health care exec told me that she believed the emotional maturation process of future physicians ended the day they began their pre med studies. That is a little harsh. But seriously, I work with a lot of physicians and many are very socially awkward. Long work hours and little play reinforce this problem. International travel and study on the other hand, are incredibly broadening. International service work should be mandatory for med students. Especially, for the really nerdy ones. We love you but it’s a quality of life thing - for them and everyone that has to endure them!

3) Red Carpet Medicine - Medical tourism is on the rise. What am I talking about? Well, Brits are going to France, Western Europeans are going to the former Eastern Bloc, Americans are going to Australia and Mexico, etc. Why? Financial reasons. There are top-notch medical clinics especially set up for this kind of medical tourism. They cost less than home and it’s a hell of a lot more fun to go to southern France for treatment than Jersey. I am talking about boutique medicine. Enterprising med students should be visiting some of these clinics for business concept harvesting purposes. Why not make the transition to high-end boutique-style medicine catering to wealthy clients in the US? My aunt works at just this kind of a practice in the Napa area. Very lucrative and based on a smart business model that doesn’t run physicians ragged. Do your market research! Success in medicine is more than just science. It is art.

4) Humanitarian Trips - Finally, a good humanitarian trip or “medical mission” abroad does wonders for your appreciation of home as well as for your overall perspective. As a young doctor, my mom worked in Nigeria for three years. The pay was horrible, the country unstable and the heat was often unbearable. But she grew so much. When you give of yourself on this level, you often become a much happier person as a result. If the doom and gloom of American medicine start to mess with your inner balance too much, a solid trip to Haiti might be just what the doctor should have ordered:)

Alright...

You see where I am going with this. We have a long way to go if we are serious about improving the American health care environment. But we can start with being purposeful about creating a more internationally-rounded vision of the medical field. And what better way to do that than to rack up some frequent flyer miles!

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Shit Med Students Say, An Interview With The Creators

Left to Right - Emily, Alessa, Annie

Emily Silverman, Alessa Colaianni, and Annie van Beuningen are members of the Johns Hopkins School of Medicine class of 2014. They are also the creative genius behind the viral video "Shit Med Students Say" and are the reason I now ask all my patients if they have bombastic diarrhea.

They where nice enough to take some time out and answer some questions about surving med school with a sense of humor.

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I thought Hopkins was a place for serious students, the who's who of serious gunners, how are you guys so funny and laid back?

EMILY: I don’t know about gunners. But we are nerds. For instance, I’ve had no trouble finding classmates who share my love for Ocarina of Time and Battlestar Galactica.

ALESSA: Oh, that thing about Hopkins being the who's who of gunners is a total myth. Ha ha ha (dismissive/uncomfortable laugh). Now if you'll excuse us, we have to go print out decoy notes with mistakes on them to throw our classmates off our knowledge trail. Right after we cure cancer in our secret labs.

ANNIE: Because the gunners here are great fodder for comedy.

How did you guys get the idea for the movie?

EMILY: When “Shit Girls Say” came out, it just seemed like a given.

ALESSA: We all loved "Shit Girls Say" and Em texted me during class suggesting that we make one for med students. We spent the rest of the class writing a script via text message.

ANNIE: We're bad med students and do things like watch every rendition of "Shit Girls Say" on YouTube rather than study the ins and outs of pseduopseudohyperaldosteronism.

How do you guys find time for this type of hobby in medical school?

EMILY: Before starting med school, I promised myself I would find a way to keep my creative side alive. Making videos is a fun way to do that, especially when you have hilarious friends like Annie and Alessa.

ALESSA: It keeps me sane. You can spend every second of your time studying during med school and still not feel like you're learning enough, and eventually you get to the point where you don't feel like a person anymore. That's not healthy. For me, it's been important to cultivate my non-medical interests as a way of staying human.

ANNIE: Studying all the time is just not feasible for me. I get to a point where I'm no longer productive or actually remembering what I'm trying to learn. Keeping up with other hobbies is a great way to break up the studying routine.

What are your medical interests?

EMILY: The only rotation I’ve done so far is pediatrics, and I loved it. But who knows. One thing I know for sure is I want to be involved in medical education. We’ve had such excellent teaching here at Hopkins, and I want to be a part of it someday.

ALESSA: I have no idea. I like everything.

ANNIE: I change my mind all the time. Right now I'm still at the point where everything is interesting to me.

Any plans for future projects?

EMILY: I’m sure we’ll make something again when inspiration strikes. As for the long term, I’d love to incorporate the arts into my career somehow. If anyone has any bright ideas, let me know!

ALESSA: Nothing in the works right now, but if you ever need someone to do voice-acting or weird accents, please call me. I’m not kidding.

Now that you finished your first two years in Medicine what do you wish you would have known before you began?

ALESSA: Turns out all those viral structures I ignored during pre-clinicals are super- important for Step 1… womp womp…

EMILY: Take notes on your laptop! Then, when it’s time to study for boards, you can Ctrl + F all the stuff you’re confused about. Brings back memories. Plus you’ll have the notes forever. ANNIE Pay attention to the acid/base disorder lectures during renal - lots of people actually have these. And CHF. Learn about CHF.

Succeding Through Failure

Learning From A "Failure" Who Won Olympic Gold

As a medical student failure is readily on the mind. The constant barrage of exams and evaluations serve as an ever present reminder that failure is always just around the corner. With aspirations of matriculating into a competitive specialty or prestigious institution dependent on every testing move you make, it's easy to get a little crazy and stressed from time to time, especially when a test may not go the way you hoped.

The truth is failure is a natural part of success. However when you are a medical student the difference between personal success and failure can be as little as a handful of questions on an exam or looking stupid on rounds in front of everyone. It's easy to question your skills and ability to become a great doctor when things don't go the way you feel that you have failed. Remembering that the absence of failure is not what defines the great physicians. Failure will happen to you at some point in your medical journey. What defines greatness is learning to use it, to push through it, to succeed in spite of it.

Mariel Zagunis knows a bit about dealing with adversity and keeping failure in perspective.

In 2004, Zagunis did not qualify to fence in the Athens Olympics. Actually she missed the last spot by one match point! Years of practice and sacrifice had all culminated to this point and she missed it by one point.

But...

Nigeria decided not to send their qualifying fencer to the tournament, and as the next highest seeded fencer in the world, Zagunis was selected to represent the United States at the 2004 Summer Olympics. Of course as an alternate who made the team by, what some would call, luck expectations on her performance where less than inspiring. However by the end of the Olympic tournament that would all change.

In her first round Zangunis defeated Japanese fencer Madoka Hisagae, 15–13.

In the quarter finals, she defeated Elena Jemayeva of Azerbaijan, 15–11.

In the semi-finals, the underdog clinched at least a silver medal by defeating Romania's Catalina Gheorghitoaia, 15–10.

Zagunis then faced Chinese fencer Xue Tan in the finals, defeating her 15–9 and become the first American to win an Olympic fencing gold medal in 100 years.

Zagunis' win surprised everyone in the fencing world. Being picked last for the team was not important, she competed as if she was the best in the world and it showed.  She returned to Beijing in 2008 and despite being ranked #6 took gold again.

Her arrival at the London games was much different. She was now a favorite to win gold, an American Hero. The only trouble is, she did not even finish with a medal. She was quoted in an interview after losing, just shy of a medal round.

“She didn’t beat me — I beat myself,” Zagunis said, adding that that is generally the case when she is beaten.

That may sound a bit arrogant, until you consider Zagunis’s current status in the world of fencing. Before the London Olympics she was ranked No. 1 in the world. She now has two Olympic gold medals and three world championships, including one — the 2010 competition in Paris — that she fenced with a fractured femur.

Zagunis' last big failure led to be the first American in 100 year to win an individual gold medal in Fencing.It will be interesting to see where this failure will take her next.

Mariel Zagunis Talks about Tough Times

The 90/30 Conundrum: How To Change The World Of Medicine

Guest post by Aaron Schenone

Is it possible to make actionable change in the healthcare industry?

I recently read an article entitled “Rebels at Work: Motivated to Make a Difference” a conversation with Lois Kelly. In her research she refers to the 90/30 conundrum where 90% of respondents agreed activating creative thinking can improve culture and drive innovation, yet only a third of those respondents were satisfied with innovative individuals’, the so called rebels, ability to provide that outcome.

Her research goes further defining these innovative individuals as creative, curious risk takers that aren’t driven by monetary gain, but by the ability to make a difference. They aren’t afraid to call out problems or be the first to do things differently. She also found people are uncomfortable with these individuals who challenge the status quo, circumvent the rules, question organizational leaders, and initiate projects without permission. Too often leaders react by throwing these habitual truants into the trapped box with the label “Rebel” on it.

It’s no surprise that innovative individuals gravitate to the world of entrepreneurship, starting their own organizations where they can create a culture that not only understands their purpose, but more importantly can provide an outlet for their ideas to make a difference in the world. We intuitively know some of these types of individuals such as Steve Jobs, and Richard Branson, but these individuals are in every industry and industry leaders are starting to recognize their value. People like Carmen Medina, former CIA Deputy Director of Intelligence, who supported the creation of a novel and dynamic approach to searchable actionable intelligence through a program affectionately called Intellipedia.

In medicine many of our innovative medical students and residents have had similar frustrations often being misunderstood and thrown into the trapped box with the label “Cowboy” on it. We feel misunderstood, locked out and all too often make an early exit from the very organizations and patients who need our ideas the most. I believe the 90/30 conundrum is a reflection on the challenges innovative people and organizational leaders have had in attempting to build trusting, productive relationships. It’s something that as innovative minded medical students and residents many of us have been battling since we sat in our first years of didactic lectures. We continue to ask whether actionable change is possible in such a large numbers driven industry.

Today, I believe it is possible to make actionable change in the healthcare industry. But to get there we must first gain the trust of our leaders. We must prove we’re not just cowboys without a cause; we’re passionate activists ready to drink H. Pylori to prove there’s a better way.

About: Aaron Schenone Third Year Medical Student in St Louis, studying clinical research in oncology

Medschool + Sharing

Two years ago I sat with my fellow students in the auditorium like newly minted pennies, fresh, enthusiastic, bright eyed and ready to mount up on our journey into the unknown world of medical school matriculation. Our enthusiasm was our armor against what we all felt, the fear of god raining from the sky smiting us out of medical school with the doomed possibility of failure.  We had all heard of at least a story of the mishaps or misfortune of a poor medical soul lost to the abyss. It was a thought we couldn’t entertain, our enthusiasm alone would will us past our insecurities.

The all mighty validation of medical knowledge affectionately called the mean, ruled whether we were on track to medical success.  Below the mean meant a darker sky, less enthusiasm, more pessimism. By the end of first year we were so good at reading each other, we could split the class in half by disposition alone.

While reflecting on first year, I took the the time to explore medicine outside the semi lit lecture hall. I read case files, sat in on tumor boards, attended grand rounds and visited patients. I saw the lives of residents and innovative leaders share their latest medical research. I saw a collaborative world where patients were put before board scores, publications, edging out peers and politics. They were candid about limitations and honest about missteps in treatment plans. I couldn’t help, but wonder if there was something intangible in medical practice that we all shared that went beyond valid assessment by neatly organized test scores.

Returning to second year the stakes were higher, the work load larger and of course our time more limited. We weren’t shiny matriculated pennies anymore, but our armor was still intact. After all we had survived first year, we could do anything. But as second year took hold, fatigue crept in and boards loomed, our armor began to crack. Enthusiasm wasn’t sustaining us anymore. We became more candid and open about missteps and limitations. We started to share study guides more openly, and compensate for each other’s missteps to save our friendly simulated patients. As our armor continued to break down we had only one thing left in our arsenal, we shared our gifts.

About: Aaron Schenone Third Year Medical Student in St Louis, studying clinical research in oncology.