Concepts of time management from the previous podcast coupled with concepts of creating efficient working spaces unleashes the strength of routine to shape an efficient and competent surgical practice. Routine allows us condition ourselves toward desired behaviors and consistency in routine allows us to be creative in unexpected ways. Reading and References: Think Like a Monk, Peak Performance, The Last Dance, On Writing: A Memoir of the Craft.
Welcome to Episode Two of operating with Zen. In the first episode, we discussed time awareness, and how an intentional approach to time management can lead to better work life balance, and a better approach to our surgical careers. In Episode Two, we're going to continue the concept of working within our dimensions and mastering our dimensions. But we're going to add in space, how do we master our space in the spaces around us? But then adding time and space together? How do we unlock the power of routine, and routine has two really unique benefits. The first is that it helps condition us towards a desired outcome, right? Human beings are just our animals. And we can condition our behaviors to achieve the outcomes we want. And by intentionally and thoughtfully creating routine, we can help move towards the outcome that we want. Instead of just living in a routine or living in a situation where we do just what feels good, we still may get to the outcomes we want. But being more thoughtful and intentional about that may really help us move more rationally, towards that outcome. The second thing routine does is it allows preservation of brain power. And our next podcast will focus specifically on brain power in the science behind brain power. But what we're going to discuss today, while saving some brain power and not using it to determine daily routines, but to have those routines established, it facilitates creativity and spontaneity. And just as last podcast talked about how time efficiency can promote a healthy practice and balance, the combination of time space and routine here is going to help maximize our efficiency towards a goal. So I really do love the book, think like a monk by Jay Shetty. I think there's a lot of great concepts there in a in a monk like approach to life. But one of the great quotes I think, from that book is that location or space has energy, and time has memory. So as we think about routines, and we think about our spaces, we can optimize the energy of those spaces, we can use the conditioning created by repetitive time to help generate routine. And so if we do something at the same time, every day, it becomes easier and more natural. If we do something in the same space every day, it also becomes more easy and natural. One of the great examples of this is Stephen King. In his memoir, he talks about his writing cave. This is his his work area, it's intentionally set up, his desk materials are specifically selected to help with his creative process. And he blasts ACDC metallic a Guns and Roses and heavy metal to put him in the right space to be creative. And he says most of us do our best work in a place of our own. Now I'm not necessarily suggesting that you Blair heavy metal. But setting up your workspace to achieve the outcome you want is really important. One of the places where music often plays a role is in the operating room. And we can talk about setting up your operating room and the sounds in your operating room to be successful. And for some people that is AC DC and Metallica and heavy metal for other people that show tunes or jazz. In my operating room. A successful or for me is when my staff is happy. So I typically let residents, fellows nurses and techs, occasionally even the anesthesiologist choose the music to set the mood for the day and put everybody in a successful mindset and environment and timing to a certain extent contribute to our conditioning. So if we link cues and routines and contexts for example, the time of day we're doing something, we can conditioned our bodies and our minds to achieving a good outcome. So the take home message is really be consistent in both your time and your space to help achieve a conditioned outcome. So what are some of the space recommendations? Well, I think the easiest one is set up your x space to be conducive to x, the easiest one set up your workspace to be conducive to work. So for a surgeon or an academic surgeon like myself, my office is bright, it is energetic, I have music available because I work best when there's some music playing. I surround myself with objects that invite the desired behavior so directly behind my computer screens or diplomas, plaques and awards, things that put in my subject conscious kind of thoughts of accomplishment, and success and where we're going behind me into the sides are creative pieces of work, whether it is art that my children have done, art that patients have given me, it helps put me in a creative space in my periphery to help that creative process. Everyone's different. And I'm not saying you should set up your office as I do. But think be intentional on how you set up your office in your workspace to help achieve the outcomes that are most conducive to what you want to accomplish. If you're not an academic urologist who's writing papers or working on grants, you may want to set your workspace up to be more conducive to clinical work. multiple screens, excellent phone system, good acoustics, so you can efficiently talk to patients review imaging and labs, you can conference with your associates. Think about what you want your workspace to achieve what you want to achieve while you're there and be thoughtful in the way you set up the space. Another great example, another very easy example, is set up your sleep space to be conducive to sleep. Right, there's the classic recommendation, your bed is only for two things, and both start with S. And to be explicit, that's sleep, and sex. So in your bedroom, where you want to sleep, it should be dark, it should be comfortable, it shouldn't be inviting, you should minimize electronics, and doing other things in bed, whether it would be work, eating, I would say reading a book is okay, especially as it helps put you in a mindset for sleep but doing other activities in bed other than sleep and sex and perhaps a book, it destroys the conditioning of that space. By walking into your bedroom every night. Where you know, there's not going to be electronics, or minimal electronics, you know, you're not going to watch TV in there, you know, you're not going to have your laptop in there, your brain and your body are setting the mood for sleep and for rest, which is really part an important part of our development. Now, as a side as a, as a surgeon and a physician, it's really hard to get rid of the phone, right? whether or not we're on call, we kind of always need to be contacted. So I wouldn't keep your phone in your room, I think it's really hard to be able to detach completely from our electronics. But you certainly don't need notifications going on going off on night. And you certainly don't necessarily need it within arm's reach. If someone's going to call you and wake you up, it's okay to get out of bed. But having the excuse to just check your phone, willy nilly as you're going to bed throughout the night or as you wake up is not really a good reason to keep that phone near you. So the work in the sleep space analogies can be carried through for exercise. Set up your gym or your workout space for your eating spaces. Right your dining room, your kitchen, wherever you eat dinner should be conducive to conversation with your family if that's what you want it to be. If you set up meditation spaces, if you set up a closet, a workshop, a bathroom, a playroom for your children, be intentional and think about what you want that space to help you do and condition yourself to do it. And by linking together time and space, we create routines. And the power of routine is really that consistency of time and space. So my personal morning routine just to give you an example, I typically wake up before my alarm goes off, which is usually around between 430 and 5am. The first thing I do is not check my phone. But in fact, I set up I leave a glass of water at my bed every night. As I'm starting to age I try not to hydrate too much before bed. As as many aging men will tell you that can be problematic throughout the night. So I like to hydrate first thing in the morning. I go to the bathroom and relieve myself and I had right to my yoga area. And I do yoga and I meditate. I let my mind wake up. And what it also does is it sends intention for the day. That the priority is not the phone and not the electronics and not the news. But the intention is setting up the day for well being. I'm going to address my physical mental well being I'm going to address my mental well being and then I'm going to start tackling the day. Every day whether I'm operating or not operating I have a similar breakfast typically drink two cups of coffee. When I'm operating. My breakfast is a breakfast bar when I'm not operating. I may have a Slightly larger breakfast, which is typically something simple like fruit and oatmeal. I'm not spending a lot of brainpower on what I eat. I've changed my wardrobe. So I we're similar clothes every day. If I'm operating, I've invested in some nicer scrubs, I just pick up the next pair of scrubs, whatever color they may be, often I head in. If I'm getting dressed that day in a suit, I've organized my closet. So my suits are organized from most recently worn to least recently worn, pick up the next suit. shirts are typically white or blue. So it's not hard to match them. And I'll often ask my kids for help picking out a tie. I'm trying to minimize the brain power needed to do these kind of simple tasks throughout the day. When I come into the hospital, on an operative day, I first thing I do is I sit down at the computer, I print out my consent forms or review histories and imaging. So I'm tuned in for the day, I know exactly what's going on, I consent my patients, and then I come down and sit and have my second cup of coffee, as I work through some emails, and await the operating room to be ready. Once the operation starts, I'm fully present in the operating room. And that's what I'm doing for the rest of the day. So you can set your routine up in a similar way. consistency with breakfast consistency with wake up routine. That way, you're not spending your kind of minds energy on other things, and you're conditioning yourself to have a successful day in the operating room. So really, the power of routine is reducing the complexity of our choices. And it allows us to seek novelty in more creative areas. So the familiar creates opportunity for creative discovery. And structure facilitates creativity, because otherwise we're just aimlessly doing or we're using our creative brainpower to get through the day, rather than to make good decisions, or be thoughtful. And Coby Brian has a great quote. And just as an aside, I, I would say, I wish I had been a bigger Kobe Bryant fan when he was alive. And just over the last year I have been so impressed by the life. He led his thoughtfulness and his approach, to basketball, to family to other endeavors to success. He really is an inspirational person. One of the quotes he talks about in his structure and creativity, he says a lot of time, creativity comes from structure. And when you have those parameters and structure, within that you can be creative. And if you don't have structure, you're just aimlessly doing stuff. Not only was Kobe, an amazing basketball player who built structure into his routine for getting ready for basketball, whether it was working out or shoot around. But he built structure into those other endeavors. You know, he won an Academy Award for a movie. He taught himself how to play the piano. And he was an incredibly creative person and inspirational person. And I think there's a lot that can be said, for routine. So general routine things. Early waking, as I said, in my personal experience helps setting the tone for the rest of the day. If you set your tone immediately by picking up your phone and checking in on the news and seeing who emailed you or tweeted about you in the middle of the night, you're setting your day up to be stressful. You're setting your day up for a lot of data. And if that's who you want to be, or that's what your productive mindset is, and that's a great way to start the day. For me that doesn't work. So My day starts off a lot more peaceful and tranquil. Limit decisions on the trivial as I said, Make a routine of your morning clothes or pick those clothes up the night before. We talked about in the prior episode, knowing your kind of chronotype and knowing when your brain activity is stronger or less strong. At night, when your brain is kind of starting to slow down, that's a great time to pick up your clothes. That's somewhere where it's okay to use the brain power their use of brain power pick out your clothes, set things up for the next day. So you don't have to think about it. When your brain is sharp, eat per routine eat similar things. It doesn't have to be the exact same thing. You can certainly build in variety, but you put you can eat protein. Limit your distractions throughout the day when possible. As I've said before, and I will say again throughout this podcast get rid of the notifications on your cell phone. There is no such thing as an emergent email or Twitter post. I once again use my smartwatch only for fitness and find free time throughout the day. And when you find that free time you're actually going to find you'll fill it with the things you need the most That's where you're going to be creative. Right. So if you've built in free time, throughout your day and on Tuesday, you really need some physical activity, that's a great time to put in a short workout. If you really need to catch up on some papers or some emails, that's a great time to fill that in. If you need to cost several patients, great time to put it in, build, build free time into your routine, and you'll fill it with what you need the most. And I think the last part of this is, building in routine allows you to be intentionally successful. Another great quote from the Stephen King memoir is don't wait for them use your job is to make sure the Muse knows where you're going to be every day from nine till noon, or seven till three. If he knows, I assure you, I assure you, he'll start showing up. If you build in routine, if you build in consistency, intentionally, you'll achieve the results you want. Now, we touched on a little bit of limiting decisions and being trivial and I think that once again speaks to kind of a minimalist approach in certain things. And Michael Joyner, who's a physician at Mayo Clinic, who is a expert on human performance is known for saying in order to be a maximalist, you really need to be a minimalist. So just as I stated about some of the decisions in my life, he minimises the trivial decisions made on a daily basis, once again, clothes, food, intentionally pursues his interests. And this approach has stemmed from his academic research and his academic career. And he's now put that into his life, to continue to live successfully. And to achieve the things he wants to do. I think one of the really nice pieces of advice he gives, is to avoid gossip, and avoid politics, unless you're a politician. Right? A lot of us, especially in the last few years, have gotten really worked up about politics and really worked up about what's going on in the country in the world. But unless there's a politician on a day to day basis, there's not a lot much of us can do except get worked up over these things, doesn't mean we shouldn't be in tune to what's going on, or we shouldn't be socially active, we should be advocating for the things that need to happen in this country. But we don't necessarily need to be plugged in 24 seven to those things, it takes away from our ability to to achieve the successes we want. And along those means we should devote our limited energy only the things that really matter to us. And this is very similar to the to the thoughts put buy in in essentialism, where we want to we have to make tough decisions, we have to make trade offs. And if we do not purposefully or intentionally choose where to focus our energy, others will choose for us. So one of the best examples of intentionally living a life to achieve the outcomes you want, are monks. Think about this same haircut, in general no hair, same outfit every single day. Generally two outfits, one that you were one that gets washed, no possessions, limited outside connections and distractions, daily routine that includes chores and or work in addition to meditation, plus or minus celibacy, depending on the on the background. And this can be Buddhism, this can be Christianity, right? But the intention of a monk is to be mindful, to be enlightened to be transcendent and the things they do are designed to achieve those outcomes. I think another great example of that, that is not necessarily a monk, are athletes and great athletes. And the one that really comes to mind here is Michael Jordan. Think about our sports masters in general like Michael Jordan, like LeBron, like Kobe, Tom Brady in football, Derek Jeter. Not only are these great athletes gifted physically, not only do they have a competitive spirit that excels beyond others, but they lift their teammates, they lift other people around them with intention. If you watched the last dance on ESPN about the bowls, and Michael Jordan, you see the intention. Michael Jordan approached the game with he approached practice he approached the way he addressed his teammates all of it was to win a championship was to be better. And so you can see how routine and intention conditions yourself conditions others for the success or for the goals you set, and I find that particularly inspiration. So to kind of summarize that great performers never just hope to be at the top of their game, they create those specific conditions to elicit their personal best. But in the truly transcendent in the team sports, they create the specific conditions to elicit the best out of their teammates. And I think we can do the same in surgery, not only can we create the conditions to elicit our personal best, whether it's with patients face to face, in the operating room, in academic careers, or in our practices outside of academics. And we can generate purposeful preparation and in sports, that's called practice. But in medicine and surgery, that's preparation. So we can have high intensity preparation, followed by periods of rest, where we're getting ready for the operating room, where we're focused. Where we are visualizing we are we are coming up with plans or game plans with others. And I think there's a lot of analogy that holds true here. The other one is warm up, we can get our body and our mind ready for performance. And one of the things I didn't realize about my morning routine, which actually hasn't changed much over the last several years, is that my routine of coming into the hospital or getting in the computer printing out consents, reviewing imaging in history was a warm up for my my mind, for my performance of the day, particularly in the operating room. And it was getting me ready for what needed to happen for that patient to have the best outcome on a given day or a given surgery. And the other thing we really learned from athletes and exceptional athletes is how to embrace the energy of anxiety. Right, I do a lot of really complex operations on an almost weekly basis, tumor thrown by a retroperitoneal lymph node dissections complex, partial nephrectomies operations where the stakes can be pretty high in terms of blood loss and complications and other issues. Those are certainly anxiety provoking. And I will tell you, throughout the course of my career, and years doing this, that anxiety doesn't really reduce. But what you do is you learn to channel it in a different way. So instead of using that energy to be nervous or pace, that energy is used to motivate or to review or to generate a plan or to teach others to use that energy in a positive way. Once again, to go back to sports, that analogy holds true in sports, what you see in really successful athletes. And there's been a number of studies on this, particularly Olympic athletes. They're using that pre performance anxiety to generate successful habits and successful behaviors, instead of allowing it to be wasted. So how do we optimize our routine in surgery or medicine. So I'll give a couple of specific examples and ideas for ways you could potentially optimize your routine. So in the operating room, we will all want to use our timeouts to review imaging history, that patient story, make sure everybody's on the same page. They've warmed up their brains in a similar way to I warmed up my brain in the beginning of the day. But I've now also added to the timeout and intention. And I know, we don't want to add too much to timeouts we're already talking about where fire extinguishers are in operating rooms. We operate on a regular basis. But I think it's helpful to really set an intention for the day and sometimes this is a mindful intention. And I typically let the residents or the nurses or the techs pick an intention for the day. Sometimes things like patience, or focus, or kindness. But sometimes it's a real surgical skill. So we may focus or set an intention for economy of motion. No wasted movements. Today, let's be really precise with what we're doing. It may be as simple as minimal blood loss during a complex nephrectomy. It may be that a resident really wants to focus on understanding pelvic anatomy. And so we all intentionally approach that for the day. And I think that's a really nice way to set the mood and to put people or condition them for a good outcome and for good learning, particularly in an academic environment. in the operating room, we take a consistent approach to every surgery we do. So for instance, partial nephrectomy is one of most common operations I do, I try not to teach that operation or any operation in steps, but instead to teach it in concepts where we're generating lateral traction, we're exposing the retro parthenium we're isolating blood vessels, we're delineating tumor. And that way, I teach my residents and I tell the residents in the fellows that I'm not teaching you how to do a partial nephrectomy or an frac to me or an RPN D. I'm teaching you principles of retroperitoneal surgery. And if you follow those principles, you're going to do any of those operations and you will do them well and you'll get yourself out of trouble if you're struggling by getting better. Back to your principles. The other beauty of teaching principles is that it evokes a visceral response when things aren't right or when things are a little bit off. And, and I learned this, from Patrick c Walsh, being fortunate to be at Hopkins and do a lot of open prostatectomy with him, he set the case up the same exact way, every single day. And he was incredibly intentional, to achieve the best outcome for that patient through minimal blood loss, excellent exposure. And so by setting up the case, and proceeding, with intention through every step, or every process, we knew when something wasn't right, if, if an endo pelvic fascia didn't open up just right with a nerve didn't peel off just right. In somebody with a more advanced cancer, that's when you start worrying about extra capsular. Extension, that's where you start worrying about, well, maybe I can't do nerve sparing in this patient or on this side. It wasn't based on the preoperative exam, per se, or a rectal examination. It was based on what he saw on the operating room. And a lot of what it was, was a visceral reaction to things deviating from the norm. I think visualization is really under appreciated. And not only before surgery, how do you think the surgery is going to play out you should be playing it over in your head. But also during surgery, when you get that visceral response and things don't look right. take a pause, visualize what you think is going to come next. Or if you're proceeding through a surgery, and things aren't going exactly how you planned or you or you encounter something different. Visualize the steps that you're going to take differently than your initial plan of attack. We do this often, particularly in complex RPL undies, or tumor thrombi, where the anatomy just wasn't what you expected, or there's bleeding in your field. And you've got to kind of take a pause. I think it's a an excellent technique that's probably underutilized. I think we also have to recognize the impact of our mood on performance. And being able to disconnect our work from life is an illusion, it's Bs, that's not really true. But what we can do is we can detach, right. And that's the really important thing, no matter what's going on in your life, no matter what's going on in clinic, no matter what's going on with your children, no matter what's going on with your assistant. That is not impactful for the patient you're operating on in the moment. And we have to be able to detach those life moments from our from our work moments and be really present at what we're doing. And while we talked about a lot of analogies between sport and surgery, I think the last thing here is it. When you're getting ready to operate or getting ready to take care of a patient, you can't really practice for that surgery, right? You're not going to practice moving your wrist or moving your hands or moving the robot. You shouldn't be practicing throwing knots, or suture materials. If you are, it's probably not suitable for you to be doing that operation. Those practicing those technical skills, right before an operation isn't going to help you perform well. Those things should have happened months, two years before that. That's why we all go through extended training programs. What you really should be focusing on is how do you get your mind and your mindset ready to take care of that patient? Do that operation and get the most out of it. So those are really my advice. for optimizing routine and surgery. Use your timeout set consistent approach to each operation. Set consistent principles. Look for visceral responses. Visualize prior to a during surgery, recognize how mood can impact your your performance and practice is for beforehand. Get yourself mentally and emotionally prepared for what you're about to do to achieve the best outcome. Thank you for listening to this episode. Hope you found it helpful. The next episode, we're going to focus on brain power optimizing our brain and how sleeping good sleep hygiene ties into that. And just as a teaser, may have given a little bit of a hint to this answer in today's podcast. But what do a Tibetan monk Steve Jobs and Mark Zuckerberg all have in common? Thanks for listening