Distress Tolerance Skills for Resident Physicians

This week’s episode of the new grand rounds is about distress tolerance skills

Welcome to this week’s episode of Promising Young Surgeon. Today we have another episode of the new grand rounds with Frances Mei Hardin. I wanted them to let me call it not your grandfather’s grand rounds with Frances Mei, but that one was left on the cutting room floor. So, anyway, here we go. This week’s episode of the new grand rounds with Frances Mei is about distress tolerance skills, how they can be a special weapon for any person, let alone, of course, students, residents and full fledged physicians. It’s not a matter of how we can completely, keep distress out of our lives, because that would really just be a fool’s errand to try. There’s always going to be stressful situations that arise, but there can be this real sportsmanship and grace to tolerating certain levels of distress and certainly mastering handling those situations. If you are working in healthcare, there’s a genuine art to what one of my older attendings used to call taking it in the jaw. And so today I will talk about some distress tolerance skills, which are based in dialectical behavior therapy by Marsha Linehan, and then ways in which we can improve our own distress tolerance, whether that’s in the operating room or for use outside of the operating room as well, in your daily life.

A high level of distress tolerance is required during high-stress surgeries

I’d like to open with a story today. When I was an intern, I joined in on, a head and neck surgery case in the operating room. And that’s for our head and neck cancer service. There’s a surgery called the salvage neck dissection, and that’s where the patient has a history of head and neck cancer. And they did already receive initial primary treatment with radiation mediation therapy. But then the disease has recurred or it’s returned. And now the lymph nodes in the neck, need to be surgically removed in the operating room. And so, yes, there’s just the straightforward neck dissection, which is any time that we take out cervical lymph nodes, in that organized fashion. But the salvage, quote, unquote, is this known, riskier, higher stakes type of case. Because radiated tissue is fibrosed, it’s scarred, and frankly, it’s damaged. It just doesn’t act like normal tissue, and it doesn’t handle as well. So, as we’re working, in the case, you know, there’s the attending surgeon. There is a mid level resident as well. And during the course of the dissection, the resident who was assisting with the case inadvertently put a tiny hole in the carotid artery. The internal carotid artery is a big deal so this is a critical vascular structure. Surgically damaging. It risks, for instance, stroke or even death. And in this case, that tiny rent. The injury was immediately recognized. The attending surgeon calmly controlled it. They kept control of that little rent while another attending physician came into the room to help repair it. And they very meticulously closed it with a proline suture, which is just the name of a specific type of suture that is used in this type of scenario. So I can tell you that no one moved a muscle or made a peep during that entire process. Surgery is a huge privilege to be able to do, and it can be life or death work. There’s no mistaking that. That’s one reason why I think that it’s so easy for people to fall back on or resort to things like shouting or intimidating others, et cetera. The work is extremely serious. It’s stressful, and so I definitely want to acknowledge that. But what this story specifically demonstrates is how critical it is to have distress tolerance skills. This is really the best case scenario because the injury was quickly repaired, the situation was well taken care of, patient did very well, and nobody freaked out in the situation. It was just kind of like, okay, this is serious. We’re going to treat it seriously. We’ll take care of it and move on. And even then, so even when everyone. Everything’s going right, and everyone has good control of their emotions, this is a super high stress situation, and it shows how serious the work is, and it shows how a necessary part of becoming a surgeon is getting nerves of steel. Every person in the room, including myself, the older resident, the attendings. A high level of distress tolerance is required to excel in these types of situations and then perform broadly high risk and complicated surgeries. Well, to give other examples, though, that’s less literal, life or death, but can still certainly feel that way. Distress tolerance skills are great for people who have had to attend meetings that they have a lot of apprehension about, or that they know that a bully is going to attend. There are just innumerable workplace situations where improved distress tolerance would come in so handy, and it truly is like a, secret superpower. So there is this absolutely wild cognitive dissonance that I personally experienced, and I think a lot of surgeons experience on the path to becoming an attending. I’ll illustrate my point with a quick trip down memory lane to my own medical school experience. And the point of sharing these stories is just to share, you know, how the culture of medicine does change depending on your level of training and things like that. Because when I was a fourth year medical student. The spring of graduation, I read House of God. This is a great fiction book by Stephen Bergen. It was published in 1978 and it is about residency training. It’s such a great book. It is harrowing. The residents in it absolutely get messed up and the culture’s abhorrent. I won’t spoil the ending, but I read that book and I ate it up. Ill read you a quote. Heres a quick excerpt from the book. And this is about internship or the first year of residency. Each of us was becoming more isolated. The more we needed support, the more shallow were our friendships. The more we needed sincerity, the more sarcastic we became. It had become an unwritten law among the terns. Don’t tell what you feel, because if you show a crack, you’ll shatter. We imagined that our feelings could ruin us like the great silent film stars had been ruined by sound. In this book, the residents were beyond hardened, jaded, and just totally beaten down. So the read is definitely hilarious at times, super depressing at times. And, I would recommend this as a read, but I sincerely, as a fourth year medical student, I read this and I was like, yeah, put me in coach, because here’s the thing. I thought it was outdated and I thought it was fiction. I knew it was published in the late seventies, and I had not really seen much like it during my own medical training. I didn’t really, like, identify with seeing those things, you know, but medical students are quite protected. They’re shielded from a lot of it. And so while I thought that I was enjoying a piece of fiction from the seventies, I was pretty unprepared to enter that world and worse, in 2017. And so I do want this to be my formal warning to people that the book is not old timey fiction. As I mentioned, I had been mostly shielded from that house of God type of environment while I was rotating in the hospital as a medical student, and even on away rotations. But I have to tell you, when I look back on it, my spidey senses went off once or twice while I was on my Ob gyn rotation. As a third year medical student, I had been assigned to a gynecologic case in the operating room. And third year medical students are primarily there in the or setting to observe, occasionally hold something or retract, and occasionally get pimped about anatomy and things like that. In this case, fortunately, it was really the former. It was just be a fly on the wall and try to absorb and learn. So you want to stay as still as possible, be quiet. Don’t attract attention in any way. And just legitimately, like, hold the wall up to an extent, especially when it’s laparoscopic surgery, you can kind of watch the screen while you’re holding the wall up. And so, that’s what I was doing that day. I quietly watched the case, and at the end of it, we jointly, you know, the whole team, rolled the patient to post op or the pacu. And while I was there thinking about, okay, well, what’s my next move? I was just kind of lingering around the Pacu when I saw the attending from the case just absolutely lay into the fellow for the case. He was raising his voice at her, just clearly berating her for something that she’d done in the case. So the fellow, this is somebody who I had just met that week, but she seemed like a very gentle, kind person. For instance, I never saw her raise her voice at anyone during those couple days. She was the mom of a few young kids. She was a wife. And I was 23 years old when I saw this exchange happen. And I was shocked, and I will tell you what shocked me about it. When you’re 23, a woman in her mid thirties, that’s, like, about as old as it gets. So I was like, this grown competent, very articulate woman in her thirties who supports a family, has excelled her whole life. Finished residency. Now she’s a fellow. She’s just being eviscerated by this old guy publicly at work. And honestly, it did give me pause. I remember seeing that like it was yesterday.

As a trainee, you see certain things that will never become you

Of course, I just quietly watched, and then I kept my head down and returned to the next task and went on and completed my medical training. I didn’t give it a ton more thought. So there’s this interesting thing as a trainee where you start to see certain things, but maybe out of self protection, you don’t think that that will ever become you? Because I can guarantee you that if someone had sat me down and said, do you see that woman’s life? That could be you for five whole years. It would be like a comic book puff of air where I had been standing, and you would never see me again. That’s how quickly I would run from that situation. I would just be like, yeah, no deal. And they could say, well, what if I told you that after working less than minimum wage for those five years, then you would get a surgeon’s salary? I would still be like, no deal. Because, yeah, honestly, as I do this postmortem on my approaching ten years of medical training, that was four years of medical school and then five years of residency training. I cannot totally say that I wasn’t warned, but the warnings were just obfuscated and I was young and hungry, so I blasted right past them. I would definitely advise people today who are looking at this career and kind of making decisions about the right fits for them to really think about what is going to fit their values and their overall goals. Of course, the caveat with everything that I’m discussing, including, like, the skills for people to use to deal with the people at work who don’t have skills, is that I don’t think that the onus is just on the student or the trainee or the young physician to take things in the jaw that would be very off brand. I don’t believe that at all. But m that being said, let’s switch to reality and practicality. We cannot control other people. We can just control ourselves. So while we continue to work big picture on things like the culture of medicine and surgery, how we train the next generation of doctors, my goal is also to arm people today with these skills so that going to work like this week and next week and so forth will be tolerable and not just totally mentally and spiritually destructive.

DBT is mindfulness, distress tolerance, interpersonal effectiveness and emotional regulation

Okay, so now let’s segue into some of these skills, some real world talk here. If you’ve ever been way over threshold, just truly at your limit with work or with an interpersonal conflict, whatever it may be, you may have googled some variation of relaxation tips, ways to decrease stress, ways to handle stress, and so forth. The results typically include some variety of one, spend time in nature, go for a walk around the block, look at a tree. Number two, listen to music that you like, three, think positively, and four, practice yoga or Tai Chi poses. Something like that. So not only is that what Google will tell you, but we literally, as residents, had HR come lecture us once a year on stress management. And those were the tips. I honestly raised my hand when she presented the slide about the music tip to just respectfully ask, what if your favorite song isn’t doing it anymore? Like, what if you’ve been awake for 30 straight hours and the chief resident is yelling at you? They’re telling you that you’re lazy and totally incompetent. So for that, do you have anything stronger than, like, the newest Selena Gomez song? Well, first of all, she seemed surprised that anyone was, like, listening or asking questions and kind of engaging with this talk. And secondly, she just kind of muttered something about taking a bath to relax when you get home and kind of moved on and if you have not experienced residency, I will tell you that advice could be a little bit misguided in the sense that she’s coming from this standpoint in the lecture where it’s as if residents don’t walk in the door late at night, many nights eat half of a granola bar and then fall asleep on the ground. I have legitimately done that more than once. So what is actually helpful for the or the operating room, and what’s interesting about the or situation specifically is that you cannot leave. So, you know, taking a lap around the block that is off the table, writing in your journal to decompress, get your thoughts out in a healthy way off the table. And often you cannot even control the music. I would love to be a fly on the wall. If people break scrub to start doing like Tai Chi or yoga poses to relax. That is also not on the table because when you are scrubbed in the operating room, sterility or maintaining like sterile conditions and total cleanliness for safety for the case that’s so crucial. And so you have to keep your hands in a, 1ft by 1ft area basically in front of your abdomen. And so that’s why you kind of see people standing goofily with like their hands just kind of on their upper belly because this is safe. This is actually still in that sterile box, which about, you know, is a foot by a foot. So, for instance, there are some very easy yoga poses that are relaxing that could be done even in a like in between scene consult situation or maybe like break from clinic situation. but in the operating room, you cannot even stretch your arms directly overhead. That would be out of kind of that sterile box and the sterile field. And so you, you’re quite limited by all of that. So that’s why it’s useful to look at some of these DBT skills and pick out ones that, that could work for the orange. As a brief background. DBT has four main pillars which include mindfulness, distress tolerance, interpersonal effectiveness and emotional regulation. The mindfulness and distress tolerance skills are acceptance skills, while the interpersonal effectiveness and emotional regulation skills are change skills. In the or situation, you need acceptance skills like for better or for worse, you’ve decided to become a surgeon or you’re a medical student who needs to get through this rotation to continue their education and to graduate. But regardless, you’re in the operating room and this is that appropriate situation to utilize acceptance skills because you cannot change the case, the environment in the or the vibes in the or the team operating. And this is also your daily reminder that you cannot change other people.

Radical acceptance means accepting reality as it is without judgment or resistance

So today we’ll discuss radical acceptance and tip skills. Radical acceptance means accepting the state of things as they are without working to change them. It’s m kind of the whole it is what it is mantra. This involves observing a situation without emotion and acknowledging that some things are simply out of our control. In other words, accept reality as it is, without judgment or resistance. So feeling out of control is just what easily can lead to feelings of emotional distress. Two tools that can help augment your practice include the half smile and willing hands. Easy to remember, pretty catchy names. Half smile is as straightforward as it sounds, and it can be done anywhere. Curl up the edges of your mouth into a half smile. Your attending won’t even know that you’re doing it, so it’s a great way for you to kind of have enough perspective and distance from the situation to say, okay, I accept this situation. I will do a nice half smile. I will continue to endure. These are things that increase your distress tolerance. And so willing hands can also be done in a variety of positions or circumstances. But it’s where you hold your hands with the palms facing up, and this can be done inside the box of sterility if you’re scrubbed in and not holding on to something. But it’s a physical gesture that’s representative of radical acceptance. And, you know, of course, the first time I heard about these, I was very skeptical. But in my own personal experience, they’ve come in quite handy a couple times. And it’s so interesting how even a small physical gesture of acceptance can really change your mindset about the situation. Other examples even include like anchoring or putting a palm down on a flat surface and anchoring yourself. And kind of that’s a way to be present and improve. Like your mindfulness practice. What if you need a pretty quick response? Tip stands for temperature, intense exercise, paced breathing, and paired muscle relaxation. The tip skills do work very quickly, within seconds to minutes, and they calm the limbic system and decrease your state of emotional arousal, and they’re just easy and safe to do in a lot of situations. So in terms of where I see a role for this, especially for the surgeon or the surgical resident or the medical student who’s kind of running around and busy both in cases or otherwise, when you are, say, in between cases, or moving from one part of the hospital to the other, or heading from a consult to clinic or clinic to consult, etcetera, you can always try temperature with cold water. There are multiple options for this, and they do range from just, like, splashing cold water on your face in the hospital bathroom or taking a cold shower or dunking your face in a bowl of ice water. That works nearly immediately. There’s one size up from the kidney basin that sometimes you could find at the hospital, and you could fill that conceivably with some ice and then put cold water in that and you would have yourself, like, a nice face dunk. And the vagal reset from that is, like, quite good. so that’s something that, yeah, you can’t do it while you’re scrubbed in, in the OR, but you could do it in between cases or something like that. And that’s better than having nothing or having no reset. Intense exercise. I think this one’s really interesting because if you have the time or ability to fit this in, it also works relatively quickly to provide an adrenaline rush and combats acute distress. So I have literally known surgeons, including attending surgeons, who sprint the stairs near the operating room in between cases. And so if you have a few minutes, you could try that. Obviously, I’m aware, for most of us, that does not sound fun. I’m not suggesting it for fun. Like, that’s kind of a nightmare. So I’d be like, okay, well, so it’s going to be kind of a high stress packed day with or cases. And then you’re saying, when I’m not in the OR, I have to be, like, sprinting on the stairs. But honestly, again, from a physical standpoint and physiologic standpoint, it really can help improve your distress tolerance. And that, that’s what we’re talking about inherently. So I have tried it before. If the answer is not sprinting, then just walk up and down a couple flights of stairs. There’s usually a set quite close to the operating rooms.

Any controlled breathing technique can help you regain control by focusing on your breath

And then, the last one I’ll go over today is paced breathing. So any controlled breathing technique really can help you regain a sense of control by focusing on your breath. There are variations to controlled breathing, but I like the Navy Seals box breathing technique just because it’s really the easiest for me to remember. You know, you hear there’s a lot of different numbers, for counts of each side of the box, but I like the four four four box just because, especially if in acute distress, like, I need numbers that are, you know, pretty accessible and easily memorized. So to try box breathing, what you do is, step one, breathe in while counting to four slowly, and you feel the air enter your lungs. Step two, hold your breath for 4 seconds at the top step three, slowly exhale through your mouth for 4 seconds. Step four, hold your breath for 4 seconds. Repeat steps until you feel recentered. And what’s nice about box breathing is that it is a very, like, non physiologic pattern of breathing. And it just helps give you, again, that little bit of distance from the situation, the ability to tolerate kind of like any external stressors, as well as a nice distraction, because you do have to focus to do it, because it’s such an unnatural pattern of breathing.

First, alternate rebellion is a way to be rebellious without being self destructive

Now, I’d love to talk about tips that you can incorporate into your life, both real life and work life, outside of the operating room. And these are just like great little pearls that have helped me a lot over the years. First, alternate rebellion. This is a way to be rebellious without being self destructive. And of course, we love a healthy coping mechanism that also keeps us out of prison. Examples of this include, for instance, wearing crazy underwear or socks, like under your scrubs, under your work clothes, piercing your ears, changing your hair, getting a tattoo. My favorite example, though, is using voodoo dolls. And there is a reason why my brand rethinking residency. Its logo is a little voodoo doll wearing a white coat. Like, that’s not a coincidence, you guys. In addition to alternate rebellion, something very practical, super helpful, I would say it changed my life. It helped set me down a path where I could take control of and change my life, is learning about cognitive distortions.

Two things that come up a lot in the hospital are fallacy of fairness and mind reading

So, two that I want to bring up today are fallacy of fairness and mind reading. Just because I think that they come up a lot in the hospital. certainly for resident physicians, things like that. So the fallacy of fairness is the belief that all things in life should be based on fairness and equality. It can be really easy to make yourself miserable perceiving some slight at work or in the hospital or in class. And, one example that I like for, say, surgery residents is that it would be nearly impossible to assign or cases in a 100% equitably distributed fashion. That’s a good one to remember. And, you know, even for medical residents, I would assume that it goes the same way with cases and patients and things like that. But the point is, we all tend to think about what we deserve. When I was a fourth year resident, I got to meet the therapist for residence at the hospital. He was the guy that AcGme allowed you to talk to for free six times per academic year. If you are a resident physician who seems like they need to talk to a therapist. So that was me. This is a wonderful resource, by the way. If you’re a resident and you have not heard of this, you know, their records are kept totally separate from the EMR. It does not report back to the program director or anything like that. So it’s just, it’s a wonderful resource. But I remember the first time that he taught me about cognitive distortions. I was a fourth year resident at the time, and he brought up the fallacy of fairness, because this is something I get really hung up on. It just absolutely grinds my gears. My dad was a lawyer. Like, it just. Just makes me crazy. But here’s what he said. There are a lot of things that have broken in our favor to get to this point, and we tend not to focus on those. Try not to get hung up on the breaks that are not in your favor. So I really loved that. I think that, like I said, these are the types of things where sometimes, we just need someone to help us have better perspective. And certainly, you know, he did that for me, therapy did that for me. And I loved, even this mantra, basically. And my mantra is try not to get hung up on the breaks that are not in your favor, because certainly so many things have broken in our favor to become a physician or surgeon.

Cognitive distortion is when you interpret an event or a situation negatively

Okay. And finally, mind reading. This one is a cognitive distortion that is very easy to fall into when working in any high stress environment. And it’s when you interpret an event or a situation negatively without evidence supporting the conclusion. So let’s say someone in the hospital snaps at you, your mind starts to race about what you could have done wrong. But in reality, most of the time, people are not thinking about you. And the behavior of snapping at you in passing is more about the person doing it and their day than it is about you. And so just, I think probably a pretty ubiquitous example I would just use is maybe like a consulting service. You know, you’re just calling someone on the phone. It is often not a person that you personally know or anything like that. Often it could be even, like, your first interaction with them. And it’s on the phone, it’s not in person, and it’s under these, you know, diffusely high stress situations, because I’m sure that you are pretty busy. Like, most of us stay busy during the day as a resident, and they also are probably very busy. And so, of course, it wouldn’t be uncommon that in that setting, like, maybe that person hasn’t eaten all day or use the restroom in 15 hours, that could be why they have a little bit of an attitude. That’s not saying that that makes it okay at all. But you can see why it just becomes really not a good use of your time to try to make sense of their behavior or attempt to read their mind about it. I think that a lot of what a resident, or really any person in the workplace who especially is in a high stress workplace, can do is they can just do all these things to try to lessen their mental load as much as possible. And things like saying, I’m, giving up mind reading to the best of my ability, that is going to lessen your mental load. But by m lessening the mental load, it will free you up to do things that are either important to you or important for your job. And so we love anything that helps us lessen the mental load.

How to respond to an insult is based on a recent Time magazine article

I’m going to do a segment now that is based on a recent Time magazine article that I read. I loved it. It was called how to respond to an insult. And so, basically, I’ve taken all their responses, and I’m going to read each one, rate them from one star to five stars based on a combination of how much I like the vibe and how effective I think they would be in the workplace for a young physician or residential. Hey, flag on the play. Okay. Obviously, my method’s not super scientific, but three stars. It might make the other person think that I know about football, which I do not, but it could endear them to me. Thanks. But I’m not accepting unsolicited feedback. One m star. Because you are going to receive an evaluation that says that you are not good at accepting feedback. It is definitely very integral to the game. I would not recommend this one. Are you okay? Four stars. I’ve seen this in a lot of different places. It is meant to disarm people and reportedly effective in tense situations. I have not tried it personally yet, in part because I’m not brave enough. But I will keep this one tucked away. I’m sure that it can be effective in the right situation. Could you repeat that? I don’t think I heard you correctly. Four stars. The only reason that it’s not a five is because I think a lot of the people I worked with in the hospital would just double down and say the insult again, just more loudly, so, you know, situational. But I definitely like what they’re getting at with this one. What a wild thing to say out loud. Four stars. The only reason that I’m not giving a, five is because I think that if there is any, like, real abuse happening, even verbal abuse, let’s say that I’m a third year and I see a more senior fifth year resident berating a second year, then I don’t necessarily think that it’s enough to just say what a wild thing to say out loud, like take a stance, because some of the stuff that we hear in the hospital is plain wrong or hateful and definitely unprofessional. So it just. It feels a little bit soft to me. What was your intention with that comment? Five stars. I will say things like this, and I have said this before, because it is effective. It can also help clear up misunderstandings because legitimately you may be misunderstanding the other person. It gives an opportunity for both parties to take a quick pause and check themselves before they wreck themselves. I know you’re likely threatened by an educated woman, but dot, dot, dot, one star. This one’s very tough because what if the person terrorizing people at work is an educated woman? One of the biggest bullies that I knew in residency training was a educated woman, middle aged. So yeah, this does not always work. Kind of. Kind of old timey. I wonder why you feel comfortable saying that to me. Five stars this is another version of check yourself before you wreck yourself. I don’t get it. Can you explain the joke? Two stars. I’ve seen this one around for many years. Personally, I don’t love it. It feels lame. It feels like you’re phoning it in a little bit. I’m a quite direct person, so it is just not something that I would say. But I can see that it’s diplomatic and it definitely would work for someone who is trying to be more indirect. Or maybe they’re in a position where the power dynamic forces them to not be able to be direct.

Frances Mei Hardin hosts a weekly podcast on medical education

Thank you for tuning in to the new grand rounds with Frances Mei Hardin. It’s a privilege to kick around ideas with you every week on the ways in which medical education gets things right and wrong and what we can change for the next generation, which starts with changing ourselves. Next week, we will have Doctor Valerie Libby on the podcast to discuss an, egg freezing pilot program that was designed specifically for surgery resident physicians, as well as the data on infertility in female surgeons and her own experience as a surgeon who underwent IVF. Follow me on Instagram at francesancesmay, MD and ethinkingresidency. Visit my website, rethinkingresidency.com to learn more about resident physician stories and ways that residents can most effectively navigate the game of residency. I cannot wait to connect with you on the next episode of Promising Young Surgeon.