Approaching Every Day with Humility in the ICU

Welcome to PICU Doc On Call, a podcast dedicated to current and aspiring intensivists. My name is Pradip Kamat.

My name is Rahul Damania, a current 3rd year pediatric critical care fellow. We come to you from Emory University School of Medicine-Children's Healthcare of Atlanta.

Today's episode is very special as we are going to be discussing 7 Habits of Highly Effective PICU fellows. As many trainees, both residents and fellows are settling into the year, We wanted to make a special podcast which highlights some key, high value habits Which can make the pediatric critical care experience very fruitful longitudinally!

We are delighted to be joined by Dr. Kevin Kuo and Dr. Paige Stevens.

Dr. Kuo is a Clinical Associate Professor, Pediatrics - Critical Care as well as the Program Director, Pediatric Critical Care Fellowship at Stanford University. Notably, Dr. Kuo is also the site creator and editor of the informational & well-known PICU website learnpicu.com- which accumulates over 10K views a month. Dr. Paige Stevens is a PCCM fellow at Stanford University and is here to provide the trainee perspective.

Dr. Kuo and Dr Stevens - we are delighted to have you. Welcome to PICU doc on call podcast.

• Dr Kuo or Stevens: Thank You Pradip and Rahul for having us on PICU Doc on Call. We have no relevant financial disclosures or conflicts of interest.

Our episode will be a series of actionable steps which can optimize your passion and performance in the PICU. This episode was inspired by the very famous book: The 7 Habits of Highly Effective People by Steven Covey which is an international bestseller.

To start with our episode, Dr. Kuo, do you mind highlighting the 7 Habits which we will cover:

• KK: Sure, here they are:
• From Dr. Covey's book we wanted to start with Begin with the End in Mind as the first habit
• Second, Embrace a Growth Mindset
• Third, Eat a Piece of Humble Pie Daily
• Fourth, Remember the ABCs
• Fifth, Put on Your Own Oxygen Mask First
• Sixth, Be Aware of the Meta
• Seventh, Sing in the Rain

Awesome, I can't wait to get into each of these. Dr. Kuo can you start us off with the first habit — Begin with the End in Mind?

• Dr. Kuo: sure
• 3 years goes by very quickly - what do you want your career to look like, what skills do you want to have gained, what things do you want to accomplish by the end of your three years, where do you want to work when you finish (academic vs community)?
• Be honest with what your interests and career goals are - i.e. not everyone needs to be an R01 funded basic scientist (although that is certainly needed and a wonderful career path).
• This is also great advice for people interviewing for fellowship. If you have a clear idea of who you want to be at the end of training, it will be easier to find a program that is going to help you get there. If you don’t know, you might want to choose a program where fellows go on to successfully do a broad range of things well.

Excellent approach and mindset especially for residents applying for PICU and matching in a few short months.

Dr. Stevens: What about the Growth Mindset?

• PS: Starting with the Growth Mindset is to
• Be active in the continual process of self-reflection and evaluating your strengths and areas for growth- use those ILP’s and conversations with your mentors.
• Be active in the continual process of seeking out feedback from others. You may not always be able to see the full perspective so seek it out from everyone you interact with.
• When you find areas for improvement after self-reflection or receive feedback from others, embrace a growth mindset and a desire to incorporate that feedback and enact change.

This habit reminds me of a great book known as Mindset: The New Psychology of Success by Carol Dwek, a PhD psychologist who has transformed the way we think about personal development, resilience, and optimism — definitely a trainee read.

Dr. Kuo, as you grow your experience as an attending what does the third habit, Eat a Piece of the Humble Pie mean to you?

• Dr Kuo:
• In the ICU we are constantly asked to be a "Jack of all Trades" ranging from a pulmonologist, to a cardiologist, to a nephrologist, to a transplant specialist, to a proceduralist... Our division chief Tim always says, "The minute you think you know it all is the day you should retire." You can't know it all and, at the end of the day, knowing and admitting what you don't know and asking for help is one of the most important things you can do.
• Additionally, even the things you think you know now (ie blood transfusion for EGDT in sepsis, looking for UTI's in RSV etc) could very well change during your years in practice.
• Approach each day with an eagerness to learn from those around you: your patients, your colleagues, your trainees, your RNs, RTs, Child Life specialists, Chaplains, etc. Ties into Covey’s “Seek first to understand, then be understood.”

Thank you for highlighting this invaluable characteristic — as ICU is a team sport humility and ego sublimation is paramount to success.

Lets transition to some productivity and self-compassion techniques - our next two habits are Remember the ABCs & Put your Own Oxygen Mask on — Dr. Kuo can you go into the prioritization of Airway Breathing Circulation in a bit more detail pls?

1. Dr Kuo: Remember the ABCs

• Just like in a resuscitation where you must prioritize the ABCs above all else, learning the art of prioritization is a skill that will go a long way in all aspects of your clinical skills and career.
• Concept of 4 quadrants (Covey): important/unimportant/urgent/nonurgent quadrants. There will always be something more that needs to be done, the real art comes in choosing your next step wisely

1. Dr Stevens: Put on Your Own Oxygen Mask First

• In order to best care for others, you need to care for yourself.
• Get in the habit of practicing self-compassion – we see and experience all sorts of challenging things in critical care- at the end of the day, we can only do our very best, continually learn, and the rest really isn’t in our hands.
• This includes building up all aspects of your life both inside and outside of medicine: relationships, finances, staying healthy: sleep, exercise, nutrition, mental health, spiritual health
• Also, surround yourself with people who can help put your oxygen mask on in case of emergencies like family/friends/spiritual community etc

This is great - lets do a quick re-cap thus far: End in Mind, Growth Mindset, Humble Pie, ABCs and O2 mask on first!

Lets round this episode off with our last two. Dr. Kuo what does Be Aware of the MEta mean to you?

1. Dr Kuo: Be Aware of the Meta

• Coming into fellowship, you’re probably worried and thinking about what induction meds to use for that intubation, how to run that code, putting in the line, when to start CRRT or cannulate for ECMO etc. -You’ll almost certainly learn that during fellowship. The “meta” is all the stuff that might not be strictly medical nor made explicit and includes things like: interpersonal interactions-ie picking up on the cue that the nurse/parent/RT etc is worried about something, team dynamics- ie facilitating autonomy for each level of learner on your team, how to run efficient yet helpful rounds, learning when/how to speak in a meeting, thinking about the meaning of the work we do, etc.) Long after you’ve learned most of the explicitly “medical” things, the meta often can be some of the most challenging and humbling parts of what we do.
• To get the most out of your training, take a step back and look at the bigger picture (“meta”) going around you. That, at least in my experience, is where more of the challenges and conflict arises and is the tougher part of the job as you get to be a more seasoned attending.
• Push yourself to see things from others' perspective and to see yourself from others' perspectives.
• Take time to recognize the “meta” of what we do. We have the privilege of taking care of children and families during the most difficult times in their lives. Take a moment to recognize the WOW factor of that privilege.

This is such a great point highlighting humanism in medicine - especially during this pandemic we have come to realize the meta in our care for children.

This has been an awe inspiring podcast today - Dr. Stevens - can you go into our last habit?

1. Dr. Stevens: Sing in the Rain

• Even though there will be challenges, remember to have fun!
• For me, these are the absolute best years of medical training. Yes, the hours may be long but you’re finally getting to do what you want to do. You’re immersed in an environment where you are constantly learning and growing. There are new challenges all the time and, even though things can be nerve wracking, you still have the backup of your attendings. You have great colleagues who you'll remember and may be friends with for the rest of your life.
• People who have fun are fun to be around. You'll be a better team leader, teacher, doctor, consultant, etc. if you find ways to make things fun.

This was an enlightening discussion - lets do a brief summary of each of today's habits:

• Begin with the End in Mind as the first habit
• Second, Embrace a Growth Mindset
• Third, Eat a Piece of Humble Pie Daily
• Fourth, Remember the ABCs
• Fifth, Put on Your Own Oxygen Mask First
• Sixth, Be Aware of the Meta
• Seventh, Sing in the Rain

Rahul-Dr Kuo Paige: What are your tips for first year fellows starting their PICU fellowship

Rahul: Especially during these challenging times due to the COVID-19 pandemic when its seems like there is no end, We advise the fellows to stay reslient and Remember these 7 habits of highly effective fellows. As budding intensivits we are on the path of life-long learning, and this episode allows for us to form a network and lead by example!

This concludes our episode today on 7 Habits of Highly Effective PICU Fellows We hope you found value in this short podcast. We welcome you to share your feedback & place a review on our podcast. PICU Doc on Call is hosted by me Pradip Kamat and my cohost Dr. Rahul Damania.

Stay tuned for our next episode! Thank you