Transcript

- Hello, ladies and gentlemen, and thank you for joining us for another session of the doubleness operative grand rounds. Our guest today is Dr. Dike Drummond from theHappyMD. He's going to be talking about one of the most important topics that concerns neurosurgeons and that's how to avoid burnout. We all work extremely hard and I believe any methods that can make our lives more healthy is important to all of us. So, Dike, I sincerely appreciate your time today, and we are all very excited to listen to your very important comments. Go ahead, please.

- Well, thank you so much, Aaron, for the opportunity. What I'm gonna do today is just present basically, what I present in a live training to my clients and client organizations. So let's just get started and dive right in 'cause I know everybody's plenty busy, so there's a little picture of me on the start and what we're gonna do today is we're gonna talk about several different things. I'm gonna show everybody the number one threat to your career as a neurosurgeon or any particular physician's career. We're gonna talk about and fill in the gaping hole in everybody's medical education. And again, this isn't specific to neurosurgeons. Everybody who absorbs the message, the patient comes first has this hole in their medical education. And last I'm gonna show you at least six different burnout prevention tools that you can put into action today and see results this week. But before we go any further, it's important, I think, that you understand how I got here and how Aaron found me and who the heck I am in the first place. So let me tell you a little bit about who I am and why I do what I do. So I graduated in 1984 from the Mayo Medical School. Mayo has a little tiny medical school on the campus in Rochester. Then I did my family practice residency in UC Davis System in Northern California. I actually did my residency in Redding, which is way up north in the state of California. And I moved to a little town halfway between Seattle and Vancouver, BC called Mount Vernon. I joined a 40 doctor multi-specialty group and real quickly I was their Executive Committee Chair Person and their Manager Medical Director back in the days of capitation. So I had leadership roles throughout. And then back in 1999, when I was 40 years old, I had a beautiful wife, two lovely young children, I was the, basically the Marcus Welby of the 1990s. Something really strange happened over about three weeks at work. It felt like every time I was going into work, that by the end of the day I was being choked out, sort of like a ultimate fighter cage match, choked out. It felt like I was dying and I didn't know what it was. Nobody came up and talked to me and said, "Hey, Dike, how are you doing?" Nobody had any advice or anything. And I thought all I needed to do is have my batteries recharged. So I was eligible for a sabbatical at the time, a month off. So I took that, but within three hours of my first shift back, I knew that I couldn't continue to be a doctor anymore. And I walked into the administrator's office and put on my notice and basically walked away from my successful family practice. Now, if anybody here is thinking about walking away from their practice, any of the people who are watching me right now, don't do that. It's not a good idea to not have a transition plan. I promise you, I set myself up for a lot of suffering. But what ended up happening is I didn't know that what I had suffered from was career-ending burnout until a couple of years later. I tried my best to recreate myself, because when you're a doctor and imagine, you know, stopping being a neurosurgeon after spending 20 years of your life trying to get where you are in your career, it took me a while of wandering in the wilderness to be certified as an executive coach, to start a training business with my ex-wife, where we were actually teaching leadership and facilitation to the Navy's Lean Six Sigma Black Belt certification program. And then in 2013, my marriage came to an end and I decided that what I was gonna do is basically focus on people, doctors, who I knew right here and right now who are feeling the same way I did in 1999. Folks that were burned out, didn't have any resources, nobody was talking to them and so I knew that there was something I could do to help 'cause I had survived it myself. I went on Google because this was 2011 at the time, I went on Google and I searched physician burnout and all I found were prevalence studies, which is of no help if you want help with your burnout. So what I did was I wrote an article, a blog post called "Physician Burnout Why It's Not a Fair Fight" that's been number one on Google for the last three years, I founded a company called thehappymd.com. At this point in time, that actual slide is out of date. I got about 6,500 physician members in 63 countries around the world. And what I do is I train and coach and consult on burnout prevention and leadership development. At this point, I have about 1500 hours of one-on-one position coaching. So everything I'm gonna show you today in the webinar are things that I've done in my own life, were done with dozens and dozens of coaching clients and I guarantee it, everything I'm gonna show you today works every time you use it. And I also work with very select group of healthcare organizations who care about their people. My experience is that most organizations don't care about the doctors. Any more than you can make RBU's, they really don't care about your quality of life or your stress level. You have to do that for yourself. So let's just get started and dive right in. So the number one threat to doctors these days is not any of the things that are flashing on the screen right now. Each one of those things is concerning in its own, right? But the real number one threat is the fact that all these things together are causing an epidemic of burnout in healthcare. And it's not just the doctors, because if you're watching this right now and you're a doctor, I guarantee you, you know a burned out nurse or two, a burned out administrator or two. Burnout is in everybody who, if you look at this group of people here at the bottom of the screen, everybody who absorbed the message, the patient comes first in their training has this same whole in their education. So, I'm trying to get these, here we go. Let's talk a little bit about burnout prevalence. So how common is burnout? Well, we've got 20 years of studies about burnout showing that on average, every study that's ever been done, is about one in three doctors are suffering from symptomatic burnout on any given office day. Now the very most interesting fact about all of this is it doesn't matter what the specialty is and it doesn't matter what nation the doctor practices in. So I can find burnout studies on American family docs, English pediatricians, Japanese neurosurgeons, and the average is gonna be about one in three. I can tell you though that almost certainly in the United States of America, that average is higher than anywhere else in the world just because of the chaos in our healthcare industry. Mergers, acquisitions, changing rules, changing reimbursement, the move from volume to value. None of those things are happening anywhere else in the world. And I would also bet that if I look at people like neurosurgeons, trauma surgeons, right? Anesthesiologists, ER doctors, people who are continuously dealing with potential tragedy, especially if you're a neurosurgeon that's on trauma call, that's gonna be a more stressful job. And your burnout rates are going to be higher simply because of the stress you're under. And again, I know nobody teaches you how to deal with it. They teach you if you have feelings or if you ask for help, you're a wimp, right? You aren't supposed to ask for help and we'll talk a little bit about that more later. So it's one in three. We don't need to do any more prevalence studies. What we need to do is get on doing something about it. So why is it important? Well, burnout has direct relationship to lower patient satisfaction, lower quality of care, higher error rates, malpractice risk, physician and staff turnover and I'm not just saying this, there's direct line research to support on every one of these statements. And what I wonder these day and age is because you're getting paid more for satisfaction and quality of care and because error rates, malpractice and turnover affect the bottom line in the organization, I want to know these days, it's sort of like the perfect storm. Where is your CFO? Because the CFO, the person in charge of the finances is now the person who should be pounding the table for burnout prevention louder than anybody else. 'Cause now for the first time, it makes bottom line financial sense to take better care of the doctors inside the system of care. So complications. Burnout causes all these things too. And I can tell you that suicide rates in physicians, whether you're a man or a woman, are double the average for people who are not physicians. So male suicide rates are double, male average for non-physicians. Female suicide rates are double average for women who are not physicians, and physician suicide is dramatically under reported. So there are myself and a couple of other people in the niche of treating burnout believe that suicide rates are actually much higher than double normal. If you were to put them all down as suicides, all the ones that are real, and they tend to occur in clusters sometimes too. So it's not uncommon for physicians to commit suicide in pairs and four or five in a row of them go down in a shorter time in a little community, like for instance, Eugene, Oregon has suffered through that. So let's just start off today's little presentation by agreeing that burnout is bad on all sorts of different levels. It's bad for the patients. It's bad for the organization. It's bad for your community. It's bad for the doctors, their families, their staff, everybody gets hurt and it's everywhere all the time. No matter how much we might want to pretend it's not here or try to sweep it under the carpet or, you know, buckle down, right. Get the work done. So what I'll maintain to you though through my work, I know it, even though it's common, it's not normal. It's something that can be identified. It's something that can be prevented and it's absolutely something that can be treated. So stress versus burnout. It's really important that we agree on what we're talking about. So when I think about the difference between stress and burnout, these are disorders of energy metabolism, but it's not the Krebs cycle. This is more like Star Wars and the force. This is your life force. And if I was to describe the way I described it, the difference between ordinary stress, because we're all under stress all the time and burnout, it goes like this. When you're simply stressed, you're able to recover. Your energy may wobble up and down day to day, but it has a baseline it never violates. If we've got somebody who's burned out, what happens is their energy begins to do a downward spiral that feels like it has no bottom. And I call it a loss of energetic homeostasis. But again, this is life force. This is not Krebs cycle and ATP and all the other simple things that we learn. Now, the person who first defined burnout is a woman named Christina Maslach, here's her name, Maslach, first name Christina. She was an organizational psychologist in the bay area in the 1970s. And she was hired by a number of very large organizations to come in and study employee engagement. And what she actually found when she studied employees of these large bay area companies was that there was a significant minority of the employees who were not just disengaged, they were disengaged in such a way that it was unhealthy for them. And her and her team coined the word burnout and created the Maslach Burnout Inventory, which is the gold standard for measuring burnout in any employed situation. So let's go over the three symptoms one at a time so we're all on the same page here. Symptom number one is exhaustion. Now, when I do a live training, I come out on the stage with every audience and I raise my hand and I say, "How many of you have ever had a day or a at work so stressful that in a quiet moment at home, you said to yourself, 'I'm not sure how much longer I can go on like this.'" And every single venue I'm in from medical school to mature organizations, every single hand goes up. So I know that this exhaustion symptom that we're talking about right here, this is something that all of us have danced with. So physical exhaustion is symptom number one. Symptom number two is what she called depersonalization, cynical, sarcastic, compassion fatigue. And actually this is a dysfunctional coping mechanism because inside us, in our psychology, we realize that the patient is one of the causes of the energy drain. And so we're trying to create a boundary between us and the patient. And it actually does feel good to vent for about 15 seconds. And the main reason that the good feeling of venting goes away really quickly is because in our venting, we've violated that prime directive. The one that I said earlier, the patient comes first. So we're being sarcastic about the very people that we're here to help. And I know for a fact, everybody does this. I mean, honestly, I'm gonna give you my email at the end of this session today, if you've never been sarcastic or cynical about patient, I want you to write me an email because you're the first person I've ever heard who doesn't do this. It's a normal thing. But I can tell you too, when you find people who say, "Hey, I need to vent. I need to complain about something." That's not normal, okay, it's not healthy. It's a sign of burnout. So you might want to look around at the situation that you're in, rather than again, shoving it under the carpet. The last symptom she called lack of efficacy. That's when a person says, "Basically, what's the use? I'm not doing anything meaningful here. Why don't I just pack it in." Another thing that some people will say at this point is, "I'm concerned that if things keep going like this, I'm gonna make a mistake and somebody is gonna get hurt." A really interesting thing is this third symptom is almost exclusively a symptom that women have. So for instance, men do not tend to doubt the quality of the work that they do. As a matter of fact, what they'll typically say is, I mean, you'll see somebody who's incredibly burned out, but what that male doctor will say to himself in the mirror is "Yeah, but I'm still doing good work." And at this point too, when you're at this stage of questioning whether or not you should keep practicing, oftentimes women will either open up to a friend and tell them they're not doing so hot or they'll actually ask for help and men do not tend to do that either. Just like we don't tend to ask for directions when we're lost in a rental car. And I think it has the same sort of origin. It's a neuroanatomical difference between men and women. We tend to be more competitive with our colleagues and our friends and women tend to klatch with each other. So it's just a big difference and I'm imagining that most neurosurgeons are men. I don't know, are they still men, Aaron?

- You know, I would say they are, although that is changing. And we're welcoming more and more women to be in our profession, but you're absolutely right. There are mostly men and I agree with you. I have heard of people saying, "I'm still doing a great job." And I think our ego, which neurosurgeons tend to have a fair amount of it prevents us from admitting our deficiencies.

- Well, and another thing that I see because it's an interesting statistic about my coaching practice is that 80% of the people hire me as a coach to help them with burnout are women. And what I see a lot is in the very procedurally oriented, typically male professions like neurosurgery, the gauntlet that a woman has to run to be certified as a neurosurgeon by the good old boys network means that they have to have a lot of the female tendencies and a lot of the things that makes them women beaten out of them along the way. They have to be more men than you are to be able to survive the program. And I think everybody who's a woman who's watching this knows exactly what I'm talking about. Great, so those are the three symptoms. Let's just go through them again. Exhaustion, sarcasm and cynicism, compassion fatigue, and the last one, lack of efficacy or doubting the quality of your work. Yeah, let's talk a little bit about burnout pathophysiology. And by that, what I mean is how burnout works inside the bodies of its victims. And I think you remember just a minute ago in the story that I told about my own history, remember I said, I thought my batteries were run down. Everybody uses that metaphor. I need to recharge my batteries and I'm gonna encourage everybody to stop it because it's a terrible metaphor and here's why. If I'm the energizer bunny, okay, and I'm pounding my little drum here and I'm walking across the floor and my battery runs out, Aaron, come on, help me out here. What do I do when my battery runs out if I'm the energizer bunny?

- Yep, you'll slowly go down.

- I stop. And here's my question, when did you ever stop? And I mean ever stop and what would have happened to your career if you had ever stopped along the way? If it was a battery analogy, every morning when you come into the hospital, you would see dead residents lying around on the hospital floor. So it's not a battery. Let me give you something much more powerful. What it is is it's an energetic bank account and it looks a lot like a bank account at a bank. So let's just go through this for just a second, because it's incredibly important concept. So it has a full mark. Right, down here, it has an empty mark. The challenges right now, we can function below empty. As a matter of fact, residency is an extended period where they push you into the red zone and see if you can take it. Now, we all survived because if you had stopped, you wouldn't have made it to where you are. That's why the battery analogy is inappropriate. But the challenge is, even though we're standing, conscious, doing good work, it's not as good a work as if we had energetic balances in the positive range. So the important thing about this is we can survive the red, however, see the white area? See the place where it's full? That's where all good things lie. So for instance, your best surgery is when you're rested, awake and alert. Your best leadership of your team is here. Your best work as a parent, as a husband, wife, significant other, father, son, daughter is all here. So each of us, each of us has a personal moral imperative to maintain a positive balance in this energetic bank account. And here's the first rule of burnout, you can't give what you ain't got. So basically, you can't give what you ain't got. And if you remember nothing else about what I teach you today, you can't give what you ain't got. And I wanna just make sure you understand this as global, we're talking about to your patients, your team, and we're talking about to your family because burnout comes home with you. If you can't be there for your patients and your staff, you certainly can't be there for your family either. Now, I also believe that it really helps to think of there being three different bank accounts, a physical account, an emotional account and a spiritual account. And these actually correspond to the three symptoms of the Maslach Burnout Inventory. So let's go through these real quick. Symptom number one is exhaustion, that corresponds to a physical energy account. And if I'm gonna make deposits into this account, just think about what would you do to support your physical body? Aaron, what would you do to make deposits into this account? How about sleep, eat good food, get exercise, right? Take good care of yourself physically, right?

- I agree.

- Yeah, think back to your residency. Didn't we have such great role models for this, right? We were taught good nutrition, we were given reasonable work hours. Our faculty were just wonderful fit, healthy human beings. You know, that's a bunch of crap, right? We never learned any of this in our residency programs. We actually learned how to take terrible care of ourselves from a physical perspective. Symptom number two, compassion fatigue corresponds to an emotional energy account. And if you're gonna make deposits in your emotional energy account. So you can be emotionally available for other people, something that's very important for a neurosurgeon. Most likely if you're working with the families of your patients, I believe that the quickest route to fill this up is healthy relationships with the people that you love in your life, your family, your kids, all the people that you love in your life. If you feel like you're spending enough time with them, this emotional account is full. And then the spiritual energy account is what corresponds to this feeling of what's the use. And I believe really strongly that in this case, the word spiritual doesn't correspond to a religious practice. Although if you have a religious practice that gives you peace and a sense of purpose, please go right ahead. What I'm talking about is the sense that you're connected with your purpose in your work, that you're working with patients who you enjoy and who say, "Thank you." and your staff is useful to you. Constructing this day-to-day connection with purpose in your work is really, really important. So I know that everybody who's listening to this call is a neurosurgeon. So they're gonna be explicitly trained to ignore their energy levels. I'm gonna ask you right now to take a breath and ask yourself physically, spiritually, emotionally, how are you doing? How is your energy? And it doesn't matter whether you're in the white or in the red. The important thing to do is to notice where you are, because if you're going to change anything at all, you have to first notice where you're starting. So take a breath right now and notice where your energy levels are. There's work to be done, now it's the time to get started. So the causes of burnout, I've noticed four of them in my work. Let's talk about them one at a time, the practice of medicine is stressful, good gosh. Being a neurosurgeon is really stressful because people are sick, hurting, scared, dying. You're not running a restaurant. You can't go in and do a good job of work without putting energy into the day. And sometimes really bad things happen when you and everybody around you gets hurt. I know everybody, who's a neurosurgeon has stories they've never told, 'cause some things have happened to you that shouldn't happen to anybody and it's part of the predictable piece of our practice of medicine. Then there's your job. So you take that practice that's already stressful and you drop it into a very specific job situation that adds layers of stress to what you're doing. And the work environment, the way that things are done, the way the ORs are scheduled, the way the crews are hired, hey, it's done sometimes by non-doctors who basically don't know what they're doing and it drives you crazy. It looks like this, here's your practice. Here's your job. Here's your color rotation, your compensation formula, your EMR, right? The fact that your hospital just got bought by a big multinational corporation two weeks ago. Now, you could change jobs, you would still have rings like this in the next job, because every job has job-specific stresses. And here's where you can actually work with your organization and work with the hospital management to make things better. But most of the time, the doctors and the administrators are banging heads with each other rather than working to make things better. Stress number three is having to have a life. Yeah, didn't we learn how to have a life in residency, right. And you either learn how to balance and recharge or you don't, okay. And here's the only study I'm gonna quote, 'cause life issues can show up as burnout at work. This study right here is a study of 3000 American surgeons and they had the surgeon and they had the surgeon's significant other in the survey. So they had both of them and they asked them one question, has there been a work-life conflict in the last three weeks, yes or no? And if either the surgeon or the surgeon's spouse said, "Yes, there's been a conflict." Here's what the surgeon's burnout rate did. Went from 26% to 47%. So people can look like they're burning out at work when what's really happened is things have changed at home and think about all the different things that could happen to you at home that would make it impossible for you to recharge when you come home from work. Marital problems, right? You get sick, your spouse gets sick, your mother-in-law gets sick, breaks her hip, moves in with you. One of your kids get sick. The list here is a hundred different things long. So whenever you're asking a friend, "Hey, how are you doing? I noticed that things sort of look like this." You have to ask them, how's it going at home? And the last piece here is the conditioning of our medical education. What happens is when you decide to become a doctor all the way back in pre-med, you start to take on these character traits because you need to have these as character traits to become successful, to make it into medical school and into residency and certainly through a neurosurgical residency. They're supposed to be tools that we use when we need them. But what happens is nobody ever shows us the off switch. So we start to live our life this way. People, when they talk about doctors will say, "Oh, doctors are such." and they'll name one of these things like workaholics. We really aren't, we turned into workaholics because we had to do that to get where we are. And wait, that's not all because there's also two prime directives. I've talked about one, patient comes first. There is another one, oh, by the way, before we go any further, you agree with me, right, that it's unhealthy for the patient to come first 24/7, 365, right? Yes, it's an unhealthy message. But most organizations are singularly focused on only what's good for the patient. We have to take into a fact what hurts the workers in the system too for them to do a good job over time. The second prime directive is never show weakness. Now, nobody talks about this but me. But imagine you had stopped. Imagine you had asked for help during your residency program. I know for a fact, your chief resident probably said to you, something like this, "Hey, I'm gonna head out now." when they're signing out at six and going home, "I'm gonna head out now, you're on call. Call me for anything you want. But remember calling me is a sign of weakness." I know they said that. Every surgeon tells me that and they aren't even neurosurgeon, general and vascular folks too. So again, something that's completely unhealthy. Here's the full boat. So a well-conditioned doctor carries all of these just under the surface. Nobody tried to do it to you, okay, they don't sit in the faculty lounge dreaming up Pavlovian thought experiments, but it's still just as powerful as basic training in the military. Here's how I know this for neurosurgeons. Just think for a second, basic training in the military is from six to 13 weeks, and in that period of time, I can get young men to walk into a live fire exercise just for asking them. Now they think it's an order and they have to obey, but that's just their conditioning. Think for a second, how long it's been from the first time you entered medical school. So your first day of medical school to your first day of private practice as a neurosurgeon, I bet it was 12 years. Do you think you were conditioned just a little bit in 12 whole years in the medical education system? This denies our humanity, blocks us from noticing our own burnout, it blocks us from helping each other. And what I see as most people who are living in Einstein's insanity definition, meaning let's get clear with each other, doing the same thing over and over again and expecting a different result. You have to do different things to get a different result. But a workaholic superhero lone ranger will definitely put their head down at work as hard as they can until they drop. So here they are, all four. And then the natural history. Basically, these are your five options. Let's focus on option number one. So first steps for you is to notice how you're feeling. Remember I said before, there's three energetic bank accounts, where's your balance? You got to notice where you are first. If you're in trouble, ask for help. Especially now that you're out and employed. Tell somebody, lean on a friend, begin to make you and your family a priority and plan and implement balance, I'm gonna show you a tool to do that in just a couple of minutes. And make some small changes at work to lower your stress. You already know what stressful at work, the challenges you're complaining about it, but not doing anything different. You have to actually make changes in a stressful thing at work if you're gonna lower your stress levels. Tweak them, use your teams. Everybody's team wants to help more unless you've completely alienated them and I hope that isn't the case. For a colleague, what I ask you to do, since you're probably concerned about somebody right now, everybody knows somebody, two or three people probably, that are burned out. I encourage you to reach out to them. And if you can see me right now, notice what I'm doing with my hand, I'm taking my doctor hat off. So if you're gonna reach out to a colleague that feels like they're going down in a downward spiral, say, "Hey, here we go. "Hey, Aaron, it's Dike. Do you have a minute?" And Aaron says, "Sure." And I say, "Aaron, I'm gonna take my doctor hat off, okay? And I'm gonna take my chief of staff hat off. This is just me to you, heart-to-heart, person-to-person. I'm concerned that you're looking pretty stressed lately. How are you?" Now, Aaron, you know the first thing that person's gonna say, just like this, right?

- I'm okay.

- They're gonna say, "I'm fine." Exactly because they can't show weakness. Now I'm gonna encourage you to be persistent with this person. Don't stalk them, but know that they're gonna deny you because that's the programming. That's what we would all do. Be persistent, come from your heart because believe me, your outreach could save their life. If I ask a whole room full of doctors, how many of you have lost a colleague to suicide? Raise your hand, typically have the room's hands go up. This is where you can make that difference. Remember, nobody had reached out to me. You can reach out to your people, this cultural thing amongst doctors doesn't have to continue this way. So that's the sort of like the sad beginning of this presentation. Take a big breath and we'll move on to number two, okay? So burnout's highest and best use is to build a more ideal practice. Burnout and the frustration and the energy drain of burnout is a sign that it's time for you to adjust your practice. You have enough experience to know what works and what doesn't for you, now you can shift the way you do things to make a more ideal practice and a more balanced life. There's three steps to doing this. And by the way, what I'm gonna teach you right now is five of the basic things I do with every private coaching client. And let's just go through them one at a time. The first thing is to ask yourself, if you had a magic wand and you could wave it and poof, your ideal practice appeared right in front of you, what is your ideal practice? So you might say to me, "Dike, in an ideal world, my practice would look like this." Boom, boom, boom, boom, boom. What you need to do is write that down. And I am very old school, what I see is take a Manila envelope, right, and put on the envelope, my ideal practice. And inside there, write down everything you can think about your ideal practice. You're working with what kind of patients, doing what kind of stuff and what kind of setting for what kind of pay with what kind of boss and what kind of team, write it all down. The second thing is to build this Venn diagram, two circles. One of them is your ideal practice and the second one is this practice. So once you have an idea of your ideal practice, compare it to your current practice and what I wanna know is what's the overlap, and specifically, I wanna know what's the overlap in percent. Most of the people that I work with that are burned out will say the overlap is about 10, 15, 20, 25%. That's a low number. People who are very happy with their practice or people who are working with me to help reverse burnout, our goal is 60, 70, 80% overlap. Typically, you can get there in three to six months if you're working hard at it. And then the last thing is, ask yourself this question, that Venn diagram, if I was gonna overlap these circles more, if I was gonna push them together, what would I change? What would you change about your practice? Well, Dike, I'd change A, B, C, D, E, F, G. Once again, that list is your master plan. Write it down and keep it in the same envelope with your ideal practice. And then torquing your practice to be more ideal is simply a question of taking one of these items on your master plan and taking action. Use your team, tell them what you're doing. I'm trying to change this thing about our practice, what do you think we can do better as a team to share the load? Don't try and lone ranger this and do it all yourself. Let your team know what's going on. And when they help you, celebrate all progress. Here is your master thank you phrase. Thanks for your hard work, we really appreciate it. You gotta be saying that to every one of your people at least once a week. And then review your ideal practice description, master plan at least quarterly because it's a moving target. Your ideal practice is different before you have children than it is after you have your first. Before you have your second child, after you have your third, when the kids leave the house, if you're single, if you're married, it's always shifting. So always keep your eye on your personal prize. And what will happen is along the way, you're gonna find some places that you struggle. And the reason you're struggling is most likely you're mistaking a dilemma for a problem. So let me teach you this really important distinctions, because any place you find a problem that just won't go away, it's probably not a problem, it's a dilemma. Here's the difference. Problems have solutions. If you apply a solution to the problem, what happens to the problem? No problem, right? Simple clinical example is a pointing abscess. What's the treatment? You don't need to tell me, it's incision and drainage, right? And if I've got a nice abscess and I I and D it, I probably have cured that person. It's a beautiful thing, we all love abscesses. It's like weeding a garden. You can see what you did and the problem is solved, right? But burnout is not a problem, it's a dilemma. It is an ongoing balancing act that never goes away. You address it with a strategy and a strategy by its nature has multiple steps. It's not a one-step solution. Here's an example of a clinical dilemma. A you know, 46-year-old, 300-pound type two diabetic. There's no way you're gonna lance the pus out of her and solve this problem. You're in a bunch of balancing act with her. So in your addressing a dilemma, you have to stop wishing for a solution. You have to develop for yourself a strategy. You have to have a system for monitoring how you're doing, and you have to be ready to tweak and adjust it for your entire career because it's not a problem that goes away. Common dilemmas in healthcare, here's several of them, burnout, work-life balance. You know, a compensation formula is a dilemma. A call schedule is a dilemma. There are things you have to balance all the time. EMR is another dilemma. So what I wanna do is show you some things about EMR, because EMR is something everybody always complains about. So let me run this by you. So EMR is a classic dilemma, the two horns or the amount of documentation that you do on one side and the amount of effort it takes on the other side, every time I've ever seen physicians surveyed about their top stresses, EMR is at least three of the top five every time it's done. So I'm pretty sure neurosurgeons hate it too. Let me give you some tools. So, you have to have a strategy to work EMR, and you have to be ready to track it and tweak it. So here's six, I think it's five components of an EMR strategy. And I want you to notice when I give you strategy components, it's not that I want you to use them all. These are things you could choose from one at a time to implement in your practice. The first strategy step is to notice if you're a hater. Haters are people who think that the devil himself wrote the EMR and his fingernails are digging into the back of your hands every time you touch a keyboard. If you literally hate EMR that bad, you've got to get over yourself, 'cause you and I both know that EMR is not going away. We also know that you can find people who like EMR and who do a really good job with it and get home on time. Those are people that I call power users. So find a power user in your organization and study them. Ask them if you can watch them chart, ask them if you can borrow their templates. 'Cause 15 minutes with a power user could show you a trick or two that'll get you home 10 minutes earlier every day. The second EMR strategy, minimal data set. Most of the people I see who have real trouble with EMR are writing the great American novel every time they sit down with the keyboard. Remember there's only three reason for a chart note, one, I'll call it continuity. So that somebody else could pick up your patient and follow after you. Second reason, medical-legal, cover your legal part. Third reason, billing. So if it doesn't have anything to do with continuity, medical-legal or billing, don't put it in the chart. You don't need complete sentences. You don't need perfect spelling. You don't need perfect punctuation and you never need to touch the semi-colon key. Strategy piece number three, use templates. Here's how I figured this out, okay, great. So I ask everybody that I work with, "Hey, do you ever feel like a broken record in your week? Do you ever feel like, oh my gosh, this is the 12th time I've written this same thing in the chart this week." That's what I call a broken record moment. Another time that it happens, by the way, not an EMR is you say, "Oh my gosh, this is the 12th time I've said the same thing to another patient this week." Well if you have broken record moments, make a list of them. Okay, so notice that it's this diagnosis, this procedure, this diagnosis, this procedure, all the broken record moments. And then what you do is once a week, you pick one off the list and you template it. If it's epic, they call it smart phrases. Every documentation system has a different nomenclature. But what you wanna do is take your list of broken record moments and once a week, you turn it into a template. Here's the fundamental beauty of templates. How many times do you have to make a template? The answer of course is once. And for how long can you use it afterwards? The answer of course is for forever. So if you just take 20 minutes a week to template one of your broken record moments in six weeks, you're getting home half an hour sooner. There's another one, team charting. I know doctors are lone rangers and surgeons are probably the worst. The real key is to ask your team, "Hey, I'm trying to get this documentation done more quickly. How can we share the load? What are your thoughts?" And let them help you more. And the last one is get a scribe. Now, I meet a lot of people who say, "Oh, I've asked for a scribe and they won't give you one." Well, let me show you how to get a scribe every single time. Here's two things an administrator thinks about that you don't. Manpower and money. So when you walk into the administrator's office and said, "If I could have a scribe, I can see more patients." Guess what the administrator is thinking in their head. Prove it. So the basic essence here is to get a scribe, you have to prove what you're telling them. In every major metropolitan area in the United States of America, there are a series of professional scribe companies. A scribe costs between 20 and $25 an hour and they will find and train the scribe for you. I suggest you do a run of production just to see how many people you see without a scribe and then you hire and train a scribe for three months and incorporate them into your practice and you pay them. You personally pay them. And then you do another run of production after they'd been incorporated into your practice and prove to your administration, you can see more than enough patients than the scribe's salary would require. Quick power tip, don't hire just one, hire two part-timers. That way, if one of them is sick, you've got somebody to cover for you. Otherwise you could be left without a scribe at all if your one scribe gets sick. So there you go. Stop being a hater, minimal dataset, template using your broken record moments, use your team and get a scribe. There's EMR strategy components, pick one and run with it. Otherwise, if you look at this and say, "Hey, I understand it." But you don't change what you're doing, guess what? You're right inside Einsteins insanity definition. You'll stay there until you change what you're doing. And EMR monitoring system is basically the time between your last patient when you get home and how much of a chart backlog you have and how much work you're doing at home. If you're logging on at home to finish your charts, there's improvements that can be made. Now burnout demands a strategy too, because it's a dilemma. Let me show you a couple of components for burnout prevention and these are work-life balance tools. The first one it's called the schedule hack. Its focus is to reign in this guy. Now imagine that you live with an 800-pound Silverback lowland gorilla. He lived in the house with you is a wild animal. How much room is this animal gonna leave you to yourself in your own house, mind you? Yeah, just a little bit. Where is he gonna poop? Wherever he wants, right? So here's the metaphor, the gorilla is your career as a neurosurgeon and the house is your life. Left unchecked, the gorilla will leave you very little room and guess what? It gets worse, so check this out. It's your job to put some boundaries around the gorilla. So let me show you how we do this because ideally, this gorilla lives in the back bedroom and the door is locked, right? Rather than roaming your whole house. So in work-life balance, the strongest structure wins. And when I talk about structure, what I'm talking about is the calendar that you carry with you at all times. Most physicians carry their calendar in their cell phone. Most of the time it's a work calendar. So if I ask you to pull out your cell phone, you could show me what your days of work are, what your call shifts are, that's all in there. But in your cell phone calendar, you probably don't have a date night or your exercise schedule or a massage or an hour to read a book or anything else that would be any life balance whatsoever. So let me show you how to do this without having to learn any extra technology. I'm gonna show you how to create a life calendar using two things you probably already have. If you have a paper calendar on the side of your refrigerator, it's a month at a time calendar. Typically, it has something like the Tetons or puppy pictures or something on it, that's perfect. All you need is a paper calendar. You'd go buy one if you don't have one and some fine point markers, right? Different colored markers. And what you do is once a week, typically, on a Sunday afternoon, you take the calendar off the refrigerator and you put it in the middle of your kitchen table and you bring your whole family around you with the pens. May you put on some music and have a little fun. But what you're gonna do is look at the week ahead, look at the week to come and you're gonna line out your life on with these colored markers. Who needs to go where amongst your kids. But again, you have to put in your life, not work. This is a life calendar. So your workouts go on here. Your date nights go on there. If you want an hour to take your kids to the zoo on your day off, that goes in there. This is a life calendar. And then all you do is you take your cellphone and you take a picture of the calendar. And now, right next to my work calendar, I have this week's life calendar. And here's what that makes possible. It makes it so that you can start to say the two-letter word of life balance. You always carry your life, your calendar with you and you can start saying no with some elegance and grace. Now I know that there are gonna be people listening to this, neurosurgeons who are in small departments. They're solo, or maybe just two docs. You got to structure your life so that you can sign out at some point in time and get a break. I can't do anything for you if you have no backup. But these times that you set up the schedule hacker for when you can get yourself some backup and you can actually be off. But here's how it works, okay? If I'm not carrying my life calendar with me and somebody says, "Hey Dike, can you take a couple extra hours next Thursday?" You know what I'm gonna say every time. I'm gonna say yes, 'cause I don't have a better reason to say no. But now I've got my life calendar. So if somebody says, "Dike, can you take a couple of hours on Thursday?" I would say, "Hang on a second. Oh man, it's date night. I'm not gonna be able to help." You know, when I say that in front of a room full of doctors, everybody stops breathing every single time. So let's just be real here. You may say yes to this person's request because you already owe them. They did a favor for you a while back, right? You may also say yes to this person's request because you want them to owe you in the future, right? You wanna put one in the bank. But most of the time you're gonna say yes, because you haven't practiced saying no enough to be comfortable with that. But here's how this little calendar will improve your life balance. If you say yes, and you've got a previous commitment, say with your wife or husband or children or a friend, you're gonna immediately see the person you need to call up and apologize to and reschedule it because you just threw your plans right under the bus. That's how this works. It works every time you use it, you'll have a more balanced week every week when you do this. Now, what it allows you to do is exactly this, align your use of time with your complete circle of not priorities, not just your job. So there it is. Once a week, get a calendar, march out the week ahead, take a picture, practice saying no. And for those of you who are not structured to have time off, work as hard as you can to get cross coverage in some way so that you actually can turn off your beeper. And if you're off call, don't take calls from the hospital. This is one of the things I have to work with everybody on. I can't count the number of times a doctor was not on call, but the nurse called and they still took the call and still answered the question. That's a missed boundary opportunity right now. Oh again, here's the boundary ritual, again, this is for when you're off call. The boundary ritual is a place that we never got taught about because every time you go into the hospital, it's just you. And then you walk into the hospital and you become Dr. Drummond, that's me, right? So there's Dr. Drummond, and there's Dike. Dike and Dr. Drummond. It's real easy for me to turn on the doctor because that's what we had to do every time our beeper went off. But the challenge is how do you turn off the doctor when you go home. And it's a boundary ritual, here is our role model. Mr. Rogers. Now, if you don't know who Mr. Rogers was before he comes through the door in the back of the stage. But you do know he has a three-part boundary ritual. He turns on Mr. Rogers by changing his cardigan, changing his shoes and singing it's a beautiful day in the neighborhood, a beautiful day for a neighbor would you be mine? And then after that, he's Mr. Rogers. So that's an example of a boundary ritual. Anybody who's listening to this who had physicians as parents, oftentimes physician parents show really good boundary rituals to their kids. Like they'll come home and they won't talk to anybody until they've changed their clothes and taken a shower. Or gone for a walk with the dog. What they're doing is this, taking the white coat all the way off so that they can begin to recharge. Because if you're sitting at home and thinking about work, you're still expending energy on your practice. So a boundary ritual is anything you do that you say it, but when you do it, you're telling yourself with this action, I come all the way home. And one of the things that really works really well is anything you can do around your home drive. So driving home, going into the house. So for instance, imagine this. Imagine you've pulled into your driveway, you've put the car in park. You have your hand on the keys and you say to yourself, "With this breath, and as I turn these keys, I come all the way home." Big breath in. As you exhale, turn the keys and take them out of the ignition. And just turn and walk into the house. Now a boundary ritual is something you were never taught. It's something you can learn how to do and with practice, it gets better and better. It works every time you do it, no matter what you do, because you'll be more relaxed and more home after you do a boundary ritual then before. And the only reason that it takes a little time to dial into your boundary ritual is because it takes some practice and practice makes better. Pure and simple, practice makes better. So that's what I have for today. Pick a boundary ritual, do the schedule hack, get your ideal job description written down, okay? Keep your master plan, be working on the things that you wanna change about your practice. Because if you don't change, you're trapped in Einstein's insanity definition. And at this point in time, I'm gonna challenge you, just like I do in a live training, okay? It doesn't matter what I teach, what matters is what you learn and what you're going to do differently now that you know this. The schedule hack, the boundary ritual, the ideal job description, working on EMR differently. Pick one of those strategy pieces, do something different, but I would only encourage you to do one thing different 'cause I know your bandwidth is already fully occupied. You don't wanna have to do too many things at once new. One at a time and incorporate them, it's like plate spinning. So if you wanna buy my book, it's called "Stop Physician Burnout". You can find it on Amazon. It's got over 117 different pieces of a potential strategy in it. It's also there from my website. I encourage you to come and check that out. And here's Einstein, by the way he says, he never said this. Doesn't make it any less powerful. Here's the opposite. To sacrifice what we are for what we could become. If you want to change the balance in your life and change the purpose and satisfaction of your practice, what got you here, won't get you there, you must change. And the last one here is B.K.S. Iyengar, he's the father of yoga in America. Here's my dream, see this word others? Take joy in the wellbeing of others. Most organizations and all of us, the way we were trained, when we see that word others, we think patient, I would love to see this others incorporate the patients, the doctors, the nurses, the staff, the MAs, everybody in the system too. When we learn how to take better care of each other, we can all take better care of our patients. And it starts with a basic awareness of stress and the unwritten rules that we were conditioned to during our educational process. That's it for today. Come visit me at TheHappyMD and Aaron, thanks again. Thanks again, thanks again for the opportunity to speak with you and your people.

- I really appreciate that, Dike. These are extremely important. All the features you mentioned, and I think the first most important thing is to admit that you are burned out. I think that the rate burn out in neurosurgeons should be much higher, just because, and you know, the challenges of neurosurgery, the patient care issues, the other aspects of profession in general and other outside pressures that seem to increase every day are so much more. And at the same time, the surgeons are so feeling strong about themselves, that admitting it is necessarily an extremely difficult point of weakness. And how could a weak person be a neurosurgeon at that paradox, doesn't go very well with neurosurgeon. So it is absolutely critical to be very relaxed, to avoid burnout because not only it improves the quality of life of patients, but also quality of life of surgeons and life is too short. We can be the greatest surgeon possible, we can be the best surgeon possible, we can be the most famous neurosurgeon possible, but at the end of the day, we're just a neurosurgeon. And what is left behind us is our great families and our legacy, not as someone who worked extremely hard to burn himself or herself out, but someone who enriched the life of others. So with that in mind, I wanna thank you again for being with us today. These are extremely good points. All the four features you reviewed should be a great lesson for all of us. And I hope that we can have you with us again in the near future, and again, thanks, Dike.

- You're welcome.

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