Latest / The Hidden Load: For the educators and leaders in medicine who hold everyone up. / From Heroics to Stewardship: Reclaiming Your Bandwidth with Dr. Stephen Cohen
Transcript
- Santina Wheat: Welcome back to the hidden load. This is the space where we name the things that are common in medicine, but definitely not normal. Today, we are talking about a specific kind of weight. It is not the weight of the patient census or even the long call hours. Welcome to the hidden load for the educators and leaders in medicine who hold everyone up. Thank you for listening to The Hidden Load. If today's conversation spoke to you, I would love for you to share it with a colleague who might need to hear it too. It's one of the simplest ways we can start shifting the culture of medicine together. We will tackle the hard topics and help you conquer your chaos and get to calm all by starting to acknowledge and remove that hidden load. It is the cognitive and moral load that lands on you simply because you are the person everyone knows that they can count on. And I'm sure that many of you can relate to that. Today, I am honored to be joined by Dr. Stephen Cohen. Stephen Cohen is a board certified colorectal surgeon, a physician educator, and a nationally recognized medical legal expert. With over three decades of clinical and surgical experience, he has served in academic leadership roles, including section chief, And remember, your time spent reflecting here matters. You can earn free CME or CE credits for listening to today's episode through the Pinnacle app. You'll find that link in the show notes. This podcast is a space for us to name the things that are common, but not normal. Each week, we'll look at the invisible weight you're carrying and explore practical coaching-based tools to help you find more calm, better boundaries, and a sense of purpose that doesn't require you to run on empty. I'm so glad that you've carved time out for yourself today. Let's get into the episode. If you are looking for one-on-one coaching support or want to dive deeper into the resources we discussed today, let's connect. with responsibility for clinical operations, faculty development, and trainee education. He is deeply involved in teaching medical students and residents and is known for translating complex clinical decision-making into clear, practical frameworks for both medical and legal audience. Steven, you have spent three decades in the House of Medicine, and you have said that much of our load isn't clinical, it's administrative and emotional. Thank you so much for coming on the show. Stephen: Thanks, Santina. It's really great to be here. And you're right, after three decades in medicine, what's become really clear to me is that the heaviest load we carry really isn't visible. It's responsibility of holding uncertainty for others while projecting steadiness in ourselves. And that's the part we're not really trained for, but it really defines how we lead. Santina Wheat: You can find information on how to reach me in the show notes. don't forget to hit subscribe so that never miss an episode ⁓ and leave me a rating so that others can find too. and take care of yourself because you deserve to be held up too. And I'll see you next time. And that walks right into something that you mentioned in the show notes beforehand that really stopped me. You called yourself a buffer. You said that you routinely absorb uncertainty and absorb system failures so that the trainees around you and the families around you can receive clarity and calm. Tell me a little bit about where that buffering shows up for you as a leader and an educator. Stephen: Yeah, that's a great question. buffering really shows up everywhere. ⁓ typical morning involves translating fragmented information into coherent plans, especially on the surgical service, ⁓ competing priorities, who's sick, who's not sick, and quietly absorbing the system inefficiencies that trainees and families experience daily instead of chaos. It's the invisible work. Intercepting problems before they escalate, making decisions without complete data sometimes, ⁓ and carrying that emotional tone of the room so others can function effectively. And over time, that buffering becomes erosive because it fragments your attention. You're pulled in three different areas, not knowing how to stratify those to do the most important thing first. And it's very difficult when you're a new learner to grasp those concepts. ⁓ Constant context switching, unrecognized decision making, consume your cognitive bandwidth. And the electronic medical record has not made it any easier, right? It's information overload. And you lose space for that strategic thinking and recovery, and everything starts to feel reactive rather than intentional. Santina Wheat: I think that this is such an important topic. And I think that this is one of those things that has been hard for leaders and faculty, especially recently. I feel like recently I have lots of leaders and educators tell me that their learners just don't get it or their team members just don't get this. And then even recently, some people saying that maybe it's gotten worse over the past few years As you mentioned, the medical record has required us to do more clicking, has more, we call them ⁓ or BPAs in our system, those different things that it makes you think about that maybe you weren't going to even talk about in that visit or deal with in that surgery. How have you seen this shift over time and potentially even become worse for some of our educators and leaders? Stephen: Yeah, there's no doubt. mean, the way we treated patients 30 years ago is very different than we do now. What's changed? I think the biggest change is more of the administrative role has switched to the physicians. It's the, you know, putting in orders. don't take verbal medicine was easy in the eighties. It was great. We didn't realize how great we had it until we saw things change. I would have 30 patients. I would have paper charts. The chart would be with me outside the patient's room. I would do my evaluation. The nurses would round with me. I would have all the labs, everything that happened the night before. I knew if they had a fever, I knew what their blood pressure was. I knew what the urine output and their Jackson Pratt drain was. I would document it. I would go to the next patient. It's not like that anymore. You have to round. You have to somehow remember everything. You have to then go sit down into the computer. And then you're now getting inundated with distractions. The nurse is calling about the patient you saw five minutes ago. The OR is calling to do your briefing. There's a patient in the clinic that just showed up. The ER is calling you. The fragmented care has really made it much more difficult now. And I think as educators and leaders, especially at my level that have been doing this, we have to realize the pressures that are put on the young learners are very different than what's put on us 30 years ago. Santina Wheat: I think you're right, not 30 years ago, but I absolutely remember as a resident walking around with my paper progress notes that were pre-filled in before we went on rounds. And I also had a paper or I had like a stack of the order forms also. And so as I would round with my attending, I was finishing those off, handing it to them so that they could co-sign my progress note with any changes that we made while we were rounding. And I was writing those orders and dropping it in the chart before we left. Stephen: Yeah Santina Wheat: I tell my residents about this and they think that it sounds silly and that they think it sounds hard. I mean, sure, I had to think about what were those orders without an order set, but the rest of it was easier. Stephen: Correct, yeah, absolutely. And the problem is, you know, especially in the learners in our facility now, we have seven surgeons. They all will round it later. They all may not have surgery that morning. And they get very irritated with the residents if they don't get their work done on their patient that morning. But they're being pulled in six different directions. It's very difficult for them. And I think that's one of the things as a leader and a section chief of managing the other surgeons to make sure they understand They're a little younger than me, but some are my age, that it's a different time and it's putting a lot of pressure on the residents that is not fair to them based on the systems that are built around us. Santina Wheat: Can you dive into that a little bit for me? How do those conversations go? How do your teammates respond when you're talking about the challenges that our learners have now? I'm definitely guilty of sometimes saying and hear others say, oh, well, they just don't understand. They just need to work harder, forgetting to take in that resident perspective. Stephen: Yeah, so I just had this conversation yesterday, believe it or not, that we have a team of five residents on our service. Two of the junior residents were out. One was sick, one was on vacation. The chief resident was managing two services, not only the 20 general surgery patients, but the 10 vascular surgery patients. She is a great resident, knowledgeable, smart, honest, trustworthy, going into surgical oncology. I would let her operate on me right now. However, one of the attendings rounded a little bit later, was irritated that his patient wasn't, the note for the day wasn't in the chart, not that she hadn't seen the patient and knew what was going on, and yelled at her and made her cry. And she was in my office in tears. And when I talked to my colleague and I said, look, this is what's going on. He didn't realize it, right? So his snarky comments to make her break down into tears when she was doing the absolute best that she could, once he realized, you know, what was going on, because he doesn't get the global picture of what was going on. My analogy is, remember in medical school, you know, you went to that anatomy class and the anatomy professor says, I want you to have the next six chapters read by tomorrow because we're moving on. And you go, okay, well, that's a lot of work. Then you go into the physiology class and the professor says, I want the next six chapters read by tomorrow. And you go, wait a second. Can you guys not communicate with each other? You want 12 chapters in one day and have it all memorized? That's what it's like. it's, the conversations aren't easy. Most of my colleagues, once they realize globally what's going on, they're more ⁓ empathetic to the fact of what they're going through. But certainly at the moment, it can be a challenge. Santina Wheat: So I also find that there's some faculty members, some leaders who understand that better than others. And so sometimes they're the ones that the residents will then, I will say, I won't say not prioritize, but they know that they understand. And so they will sometimes respond most directly to the ones that are going to. be most upset with them, right? None of us want to have that, faculty yelling at us or that person that's going to be upset. And so they arrange their life around that or their work day around that. And so then the people who understand, who are competent leaders, competent faculty, feel like they are being to, carry more themselves. They're dealing with more of the burden. And I'm just going to align this. You mentioned something called the competence trap. And I think it's not just competence. I feel like it's also the person that has the most empathy will get this too. Tell me a little bit about how you find that competence can actually increase hidden. Stephen: Yeah, so that's the paradox is that competence attracts complexity, right? It's like the best workers, they're asked to do more work, right? If you're more efficient, you're going to do more. And that was me as a surgery resident because I knew I can get it done. I could do it quickly. And my workload with 10 times the amount of everybody else. And you just did it. The more reliable you are, the more ambiguous and ill-defined problems are going to come your way. And that's a problem. I kind of call it ambiguity. Ambiguity overflow, where the system routes the messiest issues to that person least likely to drop them. The trap for all of us, me included, and all the things I'm dealing with, is internalizing that as a personal efficiency problem. It's not your problem, right? But I feel it is if I can't get it done and I'm one that never says, you need something, the answer is always yes. It's not your problem. It's a structural issue. When high functioning individuals become default solutions for poorly designed systems, their load increases in ways that aren't visible and you can't measure them. And that's really just the paradox. Santina Wheat: And I feel like those of us in medicine, we're really ripe for this. We've been taught to be overachievers our entire lives just to get here. ⁓ And those of us that fall into this paradox potentially are setting ourselves up for burnout or setting ourselves up for feeling like this career isn't sustainable or just like other people are going to pile upon us. ⁓ So. How do we manage this design flaw? How do we respond to that? Or how do you encourage your team members to do that? Stephen: Yeah, I mean, the first step, obviously, is to make that invisible workload visible. You know, start by auditing not just your time, but your energy. What kinds of decisions are draining me versus where am I adding the most value? Right. So that led to defining decision boundaries, being explicit, which problems require physician level judgment, which don't. What you can delegate, what you can't delegate. And that's a learning process, especially in the field of surgery. I mean, the only thing I used to tell the interns when I was a chief resident is your only goal for this year is to learn who's sick, right? If I tell you to do something, you're not really asking me why, just do the job. That's different as a chief resident, right? So protecting the high leverage moments means asking yourself, is my involvement essential or just habitual? Am I just doing it out of rote habit or what am I actually doing? If it's essential, then I need to be fully engaged, right? If not, I need to shift to an advisory role. I need to delegate, redirect ownership. And I think, you know, peer collaboration, finding mentors that are in that role that can help you, trusted colleagues give you a reality check. Am I overextending myself? Am I appropriately being engaged? And that was the conversation I had with the chief resident when I saw the pile of work that was put on her. you know, a little bit more delegation, I got it, this is what you need to do, you're fine, and I think that helps. But at the resident level and the medical student level, having mentors that can help you navigate those things is really helpful. Santina Wheat: I love that you said that it's different at every level. And I will say it doesn't just stop at the resident level, right? It changes when you become a fellow. changes when you become a faculty member or if you're not a faculty member, if you're leading a team. All of the way we interact with that should change as the seasons of our career, the seasons of our lives change as well. Stephen: ⁓ My background, I spent 23 years in the private sector. And for the last nine years, I've now been full-time in academics. And I think that perspective helps me a little bit because in private practice, there was no residence to do the work. Stephen Cohen did the work. So now being at ⁓ the level I am now, ⁓ it's helped me focus on what I need to do and what I can delegate to teach the residents. So I think that perspective is a little more helpful versus physicians maybe have never been in the private sector, have always had somebody to do it. And with the information overload, they want to do less. And that's just kind of natural history. Santina Wheat: And I think that's really important because we sometimes get caught in these push pulls educators and the trainees of, what's trainee level work? What's attending level work? And the truth is in some settings, it's all the same, like you just mentioned, in the private sector, it's all the same. So it's important for us to teach ⁓ learners how to do all of it because they do need to know how to do all of it. It allows us to build upon. Stephen: Yeah, it's interesting because a lot of the things that we ask them to do, they think it's just secretarial work. For example, getting the consent for the patient. Well, I mean, as the attending, the resident can get the consent. But when I was in private practice, who do you think got the consent? Patient walked into my office. They have to have a problem that requires surgery. I have to explain the risks and benefits. I get the consent. Right. So it's not just Santina Wheat: Mm-hmm. Stephen: we're putting more work on you just to do the paperwork, those are important steps. And I think explaining why it's an important step, patient is putting their faith in you that you should be their surgeon, that you're gonna get them through the surgery, and did you explain the risks and benefits and alternative procedures, that's a very important learning process that everybody needs to know no matter what level you're at. Santina Wheat: Absolutely. Right now, my specialty, family medicine, is having a lot of conversations about procedures. And one of the things that I've been talking about ⁓ in this work is that it's not just about the technical skill. It's about that whole aspect of it and the consent. Like you said, that's such an important part. Do they really understand it? Do they understand what their patient is signing up for? Do they understand why we're doing what we're doing? Which is... maybe less fun than the actual act of doing a biopsy or doing whatever our procedure is, but it's such an important aspect of learning and being able to frame it that way is something that I've been trying to encourage my team to do so that they're really meeting those residents where they are. You've mentioned that you're a surgeon and you like tools that work. And you have mentioned to me that discernment is a skill, not just a personality trait. Most of us have had times when we have felt like our load was becoming too much. When that happened for you, how did you use that discernment, yourself to figure that out and make the invisible visible, like you mentioned before? Stephen: Well, I tried to put things into three different categories. Number one, decisions you need to own, right? Decisions that are significant, clinical, ethical, or strategical impact, like the consent. Does a patient understand what happens if they don't have surgery, why we're operating? So that's number one. So must own. Number two would be should advise. The area where my input adds value, but it doesn't require full ownership. Right? I've talked to the patient, somebody needs to do the history and physical, right? I can delegate some of those things. So the should advise is number two. Number three was what can I delegate? And that's important for some people. think one of the criticisms I've always had of myself, you know, they want to say like, what's your negative attitude? I don't like to delegate, right? Because I'm a surgeon. Trust, but verify. I don't trust anybody. I wanna make sure I see the antibiotics go in pre-op. I wanna make sure they got their antibiotics 30 minutes beforehand and I'm very anal about that, but it can be overwhelming, right? So number three is what should I delegate issues other can handle for system growth and looking at it in that discipline helps me stay aligned ⁓ and especially under pressure surgical issues that can be done under pressure. Santina Wheat: And do you share those decision with your team members that you're leading? How do you encourage them to use them as well? Stephen: Well, that's a good question. I mean, think a lot of what we do as leaders, they see by example, right? So I talk them through what I'm doing, why I'm doing it, when they get overwhelmed, we walk through, why do you feel overwhelmed? Let's go through what do you need to do? What do you need input? But you might be able to let somebody else do, well, what can you delegate? And when I did that with the chief resident who was in my office crying, once I was able to offset half of her load because she could delegate. and she knew she could delegate it, but she didn't want to. And again, that's probably by criticism of her. She doesn't like to let go, some of that's a surgeon's personality, because we don't like to delegate a lot, but that's the only way you can stay grounded, stay focused, ⁓ and manage each situation as it comes out. Santina Wheat: to say not just a surgeon's personality. That is one of the hardest things that I ever had as well. It was very hard to hand up their things off to people, both as a physician and also as a leader. It was hard to let somebody else run with that project when I felt like it was mine and I put my work into it, or I was worried about the outcome. So both of those get in the way. So it's a growth space for lots of us. ⁓ Stephen: Yeah Santina Wheat: You also mentioned decision boundaries and boundaries is something that I think about a lot that I have really had to lean into myself and used to not really feel comfortable about. So for the educators listening, the leaders listening, many of them might also feel like a boundary or saying no is a sign that you're disengaged, that you don't really care about those around you. But you say it's an act of stewardship, which is is something that I have come to believe as well. Tell me a little bit about how that works and why you think it's an act of stewardship. Stephen: Yeah, that's a good question. mean, again, for me, it's hard to say no to anything, but it's reclaiming your bandwidth. I mean, there's only so many hours in the day. You the older I get, it's harder and harder to multitask. I have to stay focused on one thing. So the way I look at it is just reclaiming your bandwidth isn't disengagement. It's more stewardship, right? So if you operate in a constant state of overload, the unintentional model is unsustainable, right? And that leads to physician burnout. I mean, there's no doubt and many listening to this podcast are what's the next step for me? And, and trainees learn. And what I teach is that endurance, you know, trainees learn that endurance is not design. It's the solution. So reclaiming your bandwidth is really how you set that by setting boundaries, you create space to improve systems. rather than compensate for them. We're not gonna change the electronic medical record. You're not gonna change that there's 20 patients that you have to take care of, right? But that leads to better training environment when you can teach that and educate that and show that. That leads to better training environments, clearer roles and less reliance on individual heroics, right? It's not all me. I have a team around me and the team needs to function together. It's really a long-term investment. in people as well as in the process. Santina Wheat: I love that. I think that when you can shape those boundaries as I do really care about you, I care about you having the right access to me, I care about us doing the best things for our patients, it really does shift the conversation ⁓ and absolutely getting rid of the heroics because none of us really survive when we try to... live our careers on this thought of martyrdom feeling like we have to be the hero. When we can work as a team, we can help many more people. Tell me a little bit about the person who might be listening to us today that feels like they're constantly in a state of reactivity. ⁓ What is the first step that you would advise them if they were on your team ⁓ to ⁓ to pull back from that ⁓ move back towards intention? Stephen: Yeah, that's a great question. So I think the most important thing is start by identifying one recurring situation where you feel perpetually reactive. We all have that, right? Pause, define what good actually looks like in that scenario. What decision truly requires your level of expertise? What can you delegate? What do I need to be involved in? What do I need to own? If you're clear about that, it creates more relief. And again, I go back to my example, just by me talking to that chief resident to saying what she could delegate, half of her workload went away, right? Because she didn't want to give that up. When you're clear about where you can add value, you naturally reduce the unnecessary load and you gain a sense of control. And I think that's really the key. Santina Wheat: I love that clarity creates relief as the statement from all of that. It fits perfectly with my mission of helping people get from chaos to getting to calm. finding that clarity, ⁓ just in what is the situation ⁓ triggers us, but sometimes what is it about me in that situation that triggers us? ⁓ have learned to tell my learners my teammates that if I haven't eaten in a long time, if I haven't had water in a long time, and they think I'm being reactive for a reason that they don't quite understand, it's perfectly okay to be like, hey, do you need to go have a snack? And then they'll sort of invite them to trigger me that, oh, maybe I need to think about the fact that I'm being reactive right this moment. And it really does work. Sometimes that small amount of calm can really remind me of why I'm being reactive in those situations. Stephen: Right. It's like any relationship, right? If somebody's negative to you, sometimes you have to think, well, what happened to them to cause that reaction? You can only control the way you respond to somebody. You can't control the other person. And it's the same thing, whether it's a nurse calling you, it's the OR yelling at you, it's the staff guy yelling at you. You can control how you respond to it. You can't control their actions. Santina Wheat: So Stephen, one of my favorite questions my guests is asking about their hidden load. ⁓ I think of the hidden load as those things that we're doing every day that might be common, but that we don't really talk about and that aren't necessarily normal, but are really just adding to ⁓ feeling of not being sustainable or not being able to find the joy that we had hoped to find in this amazing career of medicine, which most of us came into for a reason. So what is the hidden load that you have faced? Stephen: Yeah, that's a good question. So certainly recently, as I am now the section chief and I have seven other physicians that I manage and 10 nurse practitioners, you know, it's like a soap opera. It's the, nobody trained me when two nurse practitioners don't get along and are fighting. And, you know, it's, those types of things and it's a learning experience. And I think, you know, it's, you know, we, we in our in our surgical service now, we have a nurse navigator and we have a nurse practitioner who cannot stand each other, but they have to work together side by side every day. And it's a challenge because they put me in the middle and why don't you stick up for me and why don't you do this and why they're doing this? You know, it's like, what am I? It's like a parent role, right? I'm their parent and that is a challenge. But I'm dealing with it, right? I think it's a good learning experience for me. If I want to continue to grow in my own practice, I'm only a section chief. At some point, I'd like to be chairman of surgery. Those are the types of things that you have to deal with. I'm also chairman of two committees, know, getting people to upload all their information so we can have a good meeting and we can make a change. We can improve patient care. Those types of things are definitely hidden loads for me. But it's a learning process. I like the challenge. It's something I was not taught in medical school. I mean, I've raised kids and I can be a referee to my kids, but being a referee to colleagues is very difficult, but it's a fun challenge. Santina Wheat: I was chuckling as you were saying the part about the kids. I do actually say that quite often of, I don't really want to treat my team as I parent my children. I have a tween and a teen, and sometimes I feel like the conversations are very similar. And then you're absolutely right. In medicine, we learn how to do the medicine. We don't learn how to negotiate these relationships past the how do we get ourselves through in that part. So I am sure that that is a load that many listeners, if they're either leaders or educators or both, are facing. before we wrap up, is there anything else that you think is really important for listeners to be thinking? Stephen: Well, I think many that listen to this podcast are feeling the burnout. They may have been in practice five, 10, 15, 20 years. You know, I will tell you that one of the things that for me that kept the joy in medicine is giving back, is some type of teaching role. I mean, if I can't teach the resident how to do something, then I don't know it myself. And that's been very meaningful for me over the years to watch these Learner start as a medical student and then match in surgery and now I'm teaching them how to do a hemorrhidectomy and a colectomy and now they're in practice and I still communicate with many of them. So the joy in medicine, it's still a great field. I would do it all over again. I would go back to surgical residency as hard as it was. I had a great time every day. ⁓ But there are a lot of things in medicine you can do that might not be clinical, right? So multiple streams of income. I give a lecture every year to the residents that you need to do something else. You can still be clinical, but having than one stream of income, staying in medicine, because that's what we've been learning for the last 30 years of your life before you became a doctor. I think that's really, really important. Santina Wheat: I think that's great. If listeners would like to reach out to you or learn from you, how do they do that? How do they get ahold of you? Stephen: Well, so I'm on LinkedIn. You can always find me on LinkedIn, Stephen Cohen. You can't miss me. But that was a great conversation. think everyone's gonna learn a lot and I appreciate the opportunity. Santina Wheat: I'm so glad that you were here. Thank you so much for joining us and sharing your wisdom. ⁓ And to the listeners, I hope that you remember that when you are listening here and you spend your time reflecting, it matters. ⁓ you can actually get continuing medical education credit for that. ⁓ There is a link in the show notes. ⁓ I will also include a link if you would like to reach out to Dr. Cohen on the ⁓ as well. And I hope that you will take care of yourselves because all of us deserve to be held up to. Thanks for joining and I hope to see you next time.