Leadership and Professional Development

“Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”

—Carl Sandburg

No one went into the practice of medicine to check off boxes. Clinicians find joy and purpose by connecting with patients and interacting with colleagues. Unfortunately, our goal of practicing in an environment that allows these experiences is threatened by extreme levels of regulatory and administrative oversight.^1,2 Decreased enjoyment and meaning in work may follow and lead to burnout, poor performance, and for some, premature departure from medicine.³ The negative effects on individuals can erode the morale and productivity of the group.

Many administrative requirements add value to clinical care. For example, interdisciplinary rounds may include a mandatory review of urinary catheters that reduces catheter-associated infections. The usefulness of some requirements, however, may promote implementation of other requirements of lesser value that interfere with the positive impact of meaningful interventions. Best Practice Alerts (BPAs) that are “clicked through” sap enthusiasm. Perfunctory monthly meetings that are informational rather than productive and exhaustive e-learning modules on institutional requirements such as “Corporate Compliance” take time away from patient care. Despite being a prominent driver of burnout, the most common approach to nuisances is nihilism. It is unrealistic for anyone with a full clinical slate to tackle pervasive irritations. Similarly, leaders may not see decreasing administrative burdens as a priority; the excitement for decreasing hassles pales relative to the excitement for developing a new vision or strategic plan.

Rather than acceptance, leaders should take proactive steps to decrease wasteful tasks. Begin by explicitly assessing the burden of tasks through dialogue with administrators, such as the chief medical officer. Administrators may not realize the impact of seemingly small requests on hospitalist workflow. For example, even adding one required question for every patient at interdisciplinary rounds can meaningfully affect the flow of rounds. Hospitalist leaders are well situated to assess the yield to burden ratio (Y/B) of any requirement. High burden tasks should be justified by substantial benefit, and tasks in which the Y/B is uncertain should be limited in scope until the value proposition is established.

The electronic medical record (EMR) deserves specific attention because it is an established source of annoyance and burnout.³ Leaders should proactively collaborate with administrators to remove EMR requirements with low Y/B. The “Get Rid of Stupid Stuff” (GROSS) program demonstrated the benefits of an innovative approach to eliminating wasteful EMR tasks.⁴ Our own institution discontinued the BPA asking clinicians to add “Chronic Kidney Disease, Stage III” to the Problem List when an assessment revealed that the Problem List was rarely updated and this BPA was frequently presented; the BPA was low yield, high burden.

Lastly, leaders should not become part of the problem. For example, a hospitalist-led quality improvement project may require documentation that a primary care physician has been contacted for each newly admitted patient. Assuming four patients and 5 minutes per call, this ask requires 20 minutes; the burden has been estimated but the yield is unknown, producing an unclear Y/B. Therefore, items generated within the group need to be vetted with the same scrutiny as external tasks.

Explicitly addressing wasteful burdens provides leaders with the opportunity to shift the emphasis from processes that distract from to initiatives that enhance patient care. Promoting a sense of meaning and purpose is an essential component of group success.⁵ Outstanding performance, productivity, and retention can only be realized through a work environment that prioritizes patients and minimizes tasks not aligned with this mission.

The authors have nothing to disclose.

“Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”

—Carl Sandburg

No one went into the practice of medicine to check off boxes. Clinicians find joy and purpose by connecting with patients and interacting with colleagues. Unfortunately, our goal of practicing in an environment that allows these experiences is threatened by extreme levels of regulatory and administrative oversight.^1,2 Decreased enjoyment and meaning in work may follow and lead to burnout, poor performance, and for some, premature departure from medicine.³ The negative effects on individuals can erode the morale and productivity of the group.

Many administrative requirements add value to clinical care. For example, interdisciplinary rounds may include a mandatory review of urinary catheters that reduces catheter-associated infections. The usefulness of some requirements, however, may promote implementation of other requirements of lesser value that interfere with the positive impact of meaningful interventions. Best Practice Alerts (BPAs) that are “clicked through” sap enthusiasm. Perfunctory monthly meetings that are informational rather than productive and exhaustive e-learning modules on institutional requirements such as “Corporate Compliance” take time away from patient care. Despite being a prominent driver of burnout, the most common approach to nuisances is nihilism. It is unrealistic for anyone with a full clinical slate to tackle pervasive irritations. Similarly, leaders may not see decreasing administrative burdens as a priority; the excitement for decreasing hassles pales relative to the excitement for developing a new vision or strategic plan.

Rather than acceptance, leaders should take proactive steps to decrease wasteful tasks. Begin by explicitly assessing the burden of tasks through dialogue with administrators, such as the chief medical officer. Administrators may not realize the impact of seemingly small requests on hospitalist workflow. For example, even adding one required question for every patient at interdisciplinary rounds can meaningfully affect the flow of rounds. Hospitalist leaders are well situated to assess the yield to burden ratio (Y/B) of any requirement. High burden tasks should be justified by substantial benefit, and tasks in which the Y/B is uncertain should be limited in scope until the value proposition is established.

The electronic medical record (EMR) deserves specific attention because it is an established source of annoyance and burnout.³ Leaders should proactively collaborate with administrators to remove EMR requirements with low Y/B. The “Get Rid of Stupid Stuff” (GROSS) program demonstrated the benefits of an innovative approach to eliminating wasteful EMR tasks.⁴ Our own institution discontinued the BPA asking clinicians to add “Chronic Kidney Disease, Stage III” to the Problem List when an assessment revealed that the Problem List was rarely updated and this BPA was frequently presented; the BPA was low yield, high burden.

Lastly, leaders should not become part of the problem. For example, a hospitalist-led quality improvement project may require documentation that a primary care physician has been contacted for each newly admitted patient. Assuming four patients and 5 minutes per call, this ask requires 20 minutes; the burden has been estimated but the yield is unknown, producing an unclear Y/B. Therefore, items generated within the group need to be vetted with the same scrutiny as external tasks.

Explicitly addressing wasteful burdens provides leaders with the opportunity to shift the emphasis from processes that distract from to initiatives that enhance patient care. Promoting a sense of meaning and purpose is an essential component of group success.⁵ Outstanding performance, productivity, and retention can only be realized through a work environment that prioritizes patients and minimizes tasks not aligned with this mission.

The authors have nothing to disclose.

“Time is the coin of your life. It is the only coin you have, and only you can determine how it will be spent. Be careful lest you let other people spend it for you.”

—Carl Sandburg

No one went into the practice of medicine to check off boxes. Clinicians find joy and purpose by connecting with patients and interacting with colleagues. Unfortunately, our goal of practicing in an environment that allows these experiences is threatened by extreme levels of regulatory and administrative oversight.^1,2 Decreased enjoyment and meaning in work may follow and lead to burnout, poor performance, and for some, premature departure from medicine.³ The negative effects on individuals can erode the morale and productivity of the group.

Many administrative requirements add value to clinical care. For example, interdisciplinary rounds may include a mandatory review of urinary catheters that reduces catheter-associated infections. The usefulness of some requirements, however, may promote implementation of other requirements of lesser value that interfere with the positive impact of meaningful interventions. Best Practice Alerts (BPAs) that are “clicked through” sap enthusiasm. Perfunctory monthly meetings that are informational rather than productive and exhaustive e-learning modules on institutional requirements such as “Corporate Compliance” take time away from patient care. Despite being a prominent driver of burnout, the most common approach to nuisances is nihilism. It is unrealistic for anyone with a full clinical slate to tackle pervasive irritations. Similarly, leaders may not see decreasing administrative burdens as a priority; the excitement for decreasing hassles pales relative to the excitement for developing a new vision or strategic plan.

Rather than acceptance, leaders should take proactive steps to decrease wasteful tasks. Begin by explicitly assessing the burden of tasks through dialogue with administrators, such as the chief medical officer. Administrators may not realize the impact of seemingly small requests on hospitalist workflow. For example, even adding one required question for every patient at interdisciplinary rounds can meaningfully affect the flow of rounds. Hospitalist leaders are well situated to assess the yield to burden ratio (Y/B) of any requirement. High burden tasks should be justified by substantial benefit, and tasks in which the Y/B is uncertain should be limited in scope until the value proposition is established.

The electronic medical record (EMR) deserves specific attention because it is an established source of annoyance and burnout.³ Leaders should proactively collaborate with administrators to remove EMR requirements with low Y/B. The “Get Rid of Stupid Stuff” (GROSS) program demonstrated the benefits of an innovative approach to eliminating wasteful EMR tasks.⁴ Our own institution discontinued the BPA asking clinicians to add “Chronic Kidney Disease, Stage III” to the Problem List when an assessment revealed that the Problem List was rarely updated and this BPA was frequently presented; the BPA was low yield, high burden.

Lastly, leaders should not become part of the problem. For example, a hospitalist-led quality improvement project may require documentation that a primary care physician has been contacted for each newly admitted patient. Assuming four patients and 5 minutes per call, this ask requires 20 minutes; the burden has been estimated but the yield is unknown, producing an unclear Y/B. Therefore, items generated within the group need to be vetted with the same scrutiny as external tasks.

Explicitly addressing wasteful burdens provides leaders with the opportunity to shift the emphasis from processes that distract from to initiatives that enhance patient care. Promoting a sense of meaning and purpose is an essential component of group success.⁵ Outstanding performance, productivity, and retention can only be realized through a work environment that prioritizes patients and minimizes tasks not aligned with this mission.

The authors have nothing to disclose.

“Becoming is better than being.”

—Carol Dweck

The words spoken about her in the staff meeting were flattering. She’d just been acknowledged with a departmental teaching award for the second year in a row. With only 3 years under her belt since completing training, the former chief resident was living up to all they’d anticipated.

Eager students requested to be on her team and colleagues delighted in sharing patients with her. “Great, as always,” her peers and learners said in hallways and evaluations. This would come to define her identity.

Things were going well. She was succeeding. But she began to wonder if this reciprocating engine of accolades represented who she truly was. Was she really that good? Was she an imposter? In her performance meetings, the feedback never wavered: “Great, as always.”

The following year she would leave for a different job.

While specific plans for growth and improvement often get laid out for struggling colleagues and learners, far less effort is devoted to coaching high performers. Feedback that consists of nonspecific compliments may hinder potential, growth, and job satisfaction. We outline strategies for preventing this professional plateau in those you lead.

In Mindset: The New Psychology of Success, psychologist Carol Dweck describes how emphasis on qualities such as “being smart” or, in this example, “great,” underscores this “fixed mindset” that certain attributes are set in stone.¹ Conversely, she defines the “growth mindset” as a belief that potential can be cultivated through efforts. Even when there aren’t obvious issues with performance, the failure, fine-tuning, and feedback necessary for resilience and, ultimately, sustained growth require intention.

Emphasize Effort

Instead of lauding an individual for being “great, as always,” consider focusing on the effort it required to get there. For example, regarding the aforementioned junior colleague who’d just won awards, a typical compliment might be: “Wow, you’re on fire!” An option, to promote a growth mindset, might be: “You work very hard at bedside teaching and innovative curriculum development. I’m happy to see that our learners and department have recognized your commitment and effort.” This language also affirms others and makes achievements seem attainable to all.

Provide Active Coaching

Identifying specific opportunities for development can challenge individuals to expand their skills. Even those who are doing well have room to become even better. Coproduction of new milestones that push beyond current comfort zones can acknowledge current achievements while encouraging continued growth—and make things personal. For example, encouraging an individual to apply to a national faculty development program, such as the Society of Hospital Medicine’s Academic Hospitalist Academy, could help them expand their skills and social network.

Offer Meaningful Feedback

Prioritizing feedback is essential for growth and peak performance. This can be particularly powerful when the observer moves beyond basic expectations to incorporate personal goals. Concrete feedback measured against individual potential then takes the place of nondescript compliments. For example, you could say: “Your teaching on systolic ejection murmurs was on target for the students. Next time I want to challenge you to broaden your teaching script to include points appropriate for more seasoned learners.” This feedback leaves them with a set of tailored “marching orders” to guide practice and improvement.

No matter where a person stands on the spectrum of performance, growth in medicine relies on deliberate practice, active coaching, meaningful feedback, and graduated opportunities. Even the most proficient among us can stagnate without these things. If we aren’t careful, this reputational inertia could amplify imposter syndrome, prevent individuals from achieving their full potential, and threaten faculty retention. Intentional work toward a growth mindset allows everyone to grow—and be seen.

The authors have nothing to disclose.

“Becoming is better than being.”

—Carol Dweck

The words spoken about her in the staff meeting were flattering. She’d just been acknowledged with a departmental teaching award for the second year in a row. With only 3 years under her belt since completing training, the former chief resident was living up to all they’d anticipated.

Eager students requested to be on her team and colleagues delighted in sharing patients with her. “Great, as always,” her peers and learners said in hallways and evaluations. This would come to define her identity.

Things were going well. She was succeeding. But she began to wonder if this reciprocating engine of accolades represented who she truly was. Was she really that good? Was she an imposter? In her performance meetings, the feedback never wavered: “Great, as always.”

The following year she would leave for a different job.

While specific plans for growth and improvement often get laid out for struggling colleagues and learners, far less effort is devoted to coaching high performers. Feedback that consists of nonspecific compliments may hinder potential, growth, and job satisfaction. We outline strategies for preventing this professional plateau in those you lead.

In Mindset: The New Psychology of Success, psychologist Carol Dweck describes how emphasis on qualities such as “being smart” or, in this example, “great,” underscores this “fixed mindset” that certain attributes are set in stone.¹ Conversely, she defines the “growth mindset” as a belief that potential can be cultivated through efforts. Even when there aren’t obvious issues with performance, the failure, fine-tuning, and feedback necessary for resilience and, ultimately, sustained growth require intention.

Emphasize Effort

Instead of lauding an individual for being “great, as always,” consider focusing on the effort it required to get there. For example, regarding the aforementioned junior colleague who’d just won awards, a typical compliment might be: “Wow, you’re on fire!” An option, to promote a growth mindset, might be: “You work very hard at bedside teaching and innovative curriculum development. I’m happy to see that our learners and department have recognized your commitment and effort.” This language also affirms others and makes achievements seem attainable to all.

Provide Active Coaching

Identifying specific opportunities for development can challenge individuals to expand their skills. Even those who are doing well have room to become even better. Coproduction of new milestones that push beyond current comfort zones can acknowledge current achievements while encouraging continued growth—and make things personal. For example, encouraging an individual to apply to a national faculty development program, such as the Society of Hospital Medicine’s Academic Hospitalist Academy, could help them expand their skills and social network.

Offer Meaningful Feedback

Prioritizing feedback is essential for growth and peak performance. This can be particularly powerful when the observer moves beyond basic expectations to incorporate personal goals. Concrete feedback measured against individual potential then takes the place of nondescript compliments. For example, you could say: “Your teaching on systolic ejection murmurs was on target for the students. Next time I want to challenge you to broaden your teaching script to include points appropriate for more seasoned learners.” This feedback leaves them with a set of tailored “marching orders” to guide practice and improvement.

No matter where a person stands on the spectrum of performance, growth in medicine relies on deliberate practice, active coaching, meaningful feedback, and graduated opportunities. Even the most proficient among us can stagnate without these things. If we aren’t careful, this reputational inertia could amplify imposter syndrome, prevent individuals from achieving their full potential, and threaten faculty retention. Intentional work toward a growth mindset allows everyone to grow—and be seen.

The authors have nothing to disclose.

“Becoming is better than being.”

—Carol Dweck

The words spoken about her in the staff meeting were flattering. She’d just been acknowledged with a departmental teaching award for the second year in a row. With only 3 years under her belt since completing training, the former chief resident was living up to all they’d anticipated.

Eager students requested to be on her team and colleagues delighted in sharing patients with her. “Great, as always,” her peers and learners said in hallways and evaluations. This would come to define her identity.

Things were going well. She was succeeding. But she began to wonder if this reciprocating engine of accolades represented who she truly was. Was she really that good? Was she an imposter? In her performance meetings, the feedback never wavered: “Great, as always.”

The following year she would leave for a different job.

While specific plans for growth and improvement often get laid out for struggling colleagues and learners, far less effort is devoted to coaching high performers. Feedback that consists of nonspecific compliments may hinder potential, growth, and job satisfaction. We outline strategies for preventing this professional plateau in those you lead.

In Mindset: The New Psychology of Success, psychologist Carol Dweck describes how emphasis on qualities such as “being smart” or, in this example, “great,” underscores this “fixed mindset” that certain attributes are set in stone.¹ Conversely, she defines the “growth mindset” as a belief that potential can be cultivated through efforts. Even when there aren’t obvious issues with performance, the failure, fine-tuning, and feedback necessary for resilience and, ultimately, sustained growth require intention.

Emphasize Effort

Instead of lauding an individual for being “great, as always,” consider focusing on the effort it required to get there. For example, regarding the aforementioned junior colleague who’d just won awards, a typical compliment might be: “Wow, you’re on fire!” An option, to promote a growth mindset, might be: “You work very hard at bedside teaching and innovative curriculum development. I’m happy to see that our learners and department have recognized your commitment and effort.” This language also affirms others and makes achievements seem attainable to all.

Provide Active Coaching

Identifying specific opportunities for development can challenge individuals to expand their skills. Even those who are doing well have room to become even better. Coproduction of new milestones that push beyond current comfort zones can acknowledge current achievements while encouraging continued growth—and make things personal. For example, encouraging an individual to apply to a national faculty development program, such as the Society of Hospital Medicine’s Academic Hospitalist Academy, could help them expand their skills and social network.

Offer Meaningful Feedback

Prioritizing feedback is essential for growth and peak performance. This can be particularly powerful when the observer moves beyond basic expectations to incorporate personal goals. Concrete feedback measured against individual potential then takes the place of nondescript compliments. For example, you could say: “Your teaching on systolic ejection murmurs was on target for the students. Next time I want to challenge you to broaden your teaching script to include points appropriate for more seasoned learners.” This feedback leaves them with a set of tailored “marching orders” to guide practice and improvement.

No matter where a person stands on the spectrum of performance, growth in medicine relies on deliberate practice, active coaching, meaningful feedback, and graduated opportunities. Even the most proficient among us can stagnate without these things. If we aren’t careful, this reputational inertia could amplify imposter syndrome, prevent individuals from achieving their full potential, and threaten faculty retention. Intentional work toward a growth mindset allows everyone to grow—and be seen.

The authors have nothing to disclose.

“In the end, we will remember not the words of our enemies, but the silence of our friends.”

—Martin Luther King, Jr.

"Code Blue, Emergency Department Code Team to PACU.” A female senior resident dons her personal protective equipment and assembles her team. An enthusiastic male junior resident asks if he can accompany her, and off they go. They encounter a frantic scene in the post-anesthesia care unit (PACU). Before the senior resident can lead the rapid response, a PACU nurse addresses the junior resident: “You are leading the code, correct? What medications would you like?”

“Microaggressions” are subtle, commonplace exchanges that—whether intentional or unintentional—communicate disparaging messages to members of marginalized groups.¹ These groups often include women, members of racial/ethnic groups that are underrepresented in medicine, and lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals. Although an individual may not intend to cause harm, their words may still negatively impact the receiving party, who regularly experiences differential treatment based on sex, race, ethnicity, or other social identities. The effects of microaggressions extend beyond personal offense to include anxiety, depression, and even hypertension.^1,2

Addressing microaggressions can be challenging. Given that the recipients of microaggressions are often burdened with responding to them, it is important for bystanders to be empowered to respond as well. A bystander witnesses and recognizes the microaggression and can address it. Based on the work of Sue et al,³ we suggest that bystanders adopt the following strategies:

• Make the “invisible” visible. Many people do not perceive their actions as biased or prejudiced. It is therefore important to bring the implicit bias to the forefront by asking for clarification, naming the implication, or challenging the stereotype.
• Disarm the microaggression. Don’t be afraid to stop, deflect, disagree, or challenge what was said or done, thereby highlighting its potentially harmful impact. Another option is to interrupt the comment as it’s being said and redirect the conversation.
• Educate the speaker. Create a nonpunitive discussion by appealing to common values, promoting empathy, and increasing awareness of societal benefits. The speaker may become defensive and emphasize that their intent was not to cause harm. You must emphasize that, regardless of intent, the impact was hurtful. You may refocus the discussion with a simple statement such as, “I know you meant well, and…”
• Seek external support when needed. Addressing microaggressions can be emotionally taxing. Don’t be afraid to utilize community services, find a support group, or seek advice from professionals.

By virtue of being a neutral third party, bystanders who intervene may have greater success at explaining the impact of the microaggression. In doing so, the bystander also relieves the recipient of the microaggression of a burdensome response. In the above example, another provider in the PACU might pull the nurse aside later and say, “When you asked the junior resident if he was leading the code, you unintentionally indicated that he was the most experienced, which made it more challenging for the female senior resident to lead the response.” In this way, the “invisible” implication of the nurse’s words—that the male resident was the most knowledgeable physician in the room—is made visible, and the female resident is relieved of responding.

Microaggressions do not occur in a vacuum; context matters. Before employing these strategies, consider when, where, and how you address microaggressions. These strategies validate and support those on the receiving end of microaggressions, and thus counteract their deleterious effects. The onus is on us: we must not be silent.

The authors have nothing to disclose.

“In the end, we will remember not the words of our enemies, but the silence of our friends.”

—Martin Luther King, Jr.

"Code Blue, Emergency Department Code Team to PACU.” A female senior resident dons her personal protective equipment and assembles her team. An enthusiastic male junior resident asks if he can accompany her, and off they go. They encounter a frantic scene in the post-anesthesia care unit (PACU). Before the senior resident can lead the rapid response, a PACU nurse addresses the junior resident: “You are leading the code, correct? What medications would you like?”

“Microaggressions” are subtle, commonplace exchanges that—whether intentional or unintentional—communicate disparaging messages to members of marginalized groups.¹ These groups often include women, members of racial/ethnic groups that are underrepresented in medicine, and lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals. Although an individual may not intend to cause harm, their words may still negatively impact the receiving party, who regularly experiences differential treatment based on sex, race, ethnicity, or other social identities. The effects of microaggressions extend beyond personal offense to include anxiety, depression, and even hypertension.^1,2

Addressing microaggressions can be challenging. Given that the recipients of microaggressions are often burdened with responding to them, it is important for bystanders to be empowered to respond as well. A bystander witnesses and recognizes the microaggression and can address it. Based on the work of Sue et al,³ we suggest that bystanders adopt the following strategies:

• Make the “invisible” visible. Many people do not perceive their actions as biased or prejudiced. It is therefore important to bring the implicit bias to the forefront by asking for clarification, naming the implication, or challenging the stereotype.
• Disarm the microaggression. Don’t be afraid to stop, deflect, disagree, or challenge what was said or done, thereby highlighting its potentially harmful impact. Another option is to interrupt the comment as it’s being said and redirect the conversation.
• Educate the speaker. Create a nonpunitive discussion by appealing to common values, promoting empathy, and increasing awareness of societal benefits. The speaker may become defensive and emphasize that their intent was not to cause harm. You must emphasize that, regardless of intent, the impact was hurtful. You may refocus the discussion with a simple statement such as, “I know you meant well, and…”
• Seek external support when needed. Addressing microaggressions can be emotionally taxing. Don’t be afraid to utilize community services, find a support group, or seek advice from professionals.

By virtue of being a neutral third party, bystanders who intervene may have greater success at explaining the impact of the microaggression. In doing so, the bystander also relieves the recipient of the microaggression of a burdensome response. In the above example, another provider in the PACU might pull the nurse aside later and say, “When you asked the junior resident if he was leading the code, you unintentionally indicated that he was the most experienced, which made it more challenging for the female senior resident to lead the response.” In this way, the “invisible” implication of the nurse’s words—that the male resident was the most knowledgeable physician in the room—is made visible, and the female resident is relieved of responding.

Microaggressions do not occur in a vacuum; context matters. Before employing these strategies, consider when, where, and how you address microaggressions. These strategies validate and support those on the receiving end of microaggressions, and thus counteract their deleterious effects. The onus is on us: we must not be silent.

The authors have nothing to disclose.

“In the end, we will remember not the words of our enemies, but the silence of our friends.”

—Martin Luther King, Jr.

"Code Blue, Emergency Department Code Team to PACU.” A female senior resident dons her personal protective equipment and assembles her team. An enthusiastic male junior resident asks if he can accompany her, and off they go. They encounter a frantic scene in the post-anesthesia care unit (PACU). Before the senior resident can lead the rapid response, a PACU nurse addresses the junior resident: “You are leading the code, correct? What medications would you like?”

“Microaggressions” are subtle, commonplace exchanges that—whether intentional or unintentional—communicate disparaging messages to members of marginalized groups.¹ These groups often include women, members of racial/ethnic groups that are underrepresented in medicine, and lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals. Although an individual may not intend to cause harm, their words may still negatively impact the receiving party, who regularly experiences differential treatment based on sex, race, ethnicity, or other social identities. The effects of microaggressions extend beyond personal offense to include anxiety, depression, and even hypertension.^1,2

Addressing microaggressions can be challenging. Given that the recipients of microaggressions are often burdened with responding to them, it is important for bystanders to be empowered to respond as well. A bystander witnesses and recognizes the microaggression and can address it. Based on the work of Sue et al,³ we suggest that bystanders adopt the following strategies:

• Make the “invisible” visible. Many people do not perceive their actions as biased or prejudiced. It is therefore important to bring the implicit bias to the forefront by asking for clarification, naming the implication, or challenging the stereotype.
• Disarm the microaggression. Don’t be afraid to stop, deflect, disagree, or challenge what was said or done, thereby highlighting its potentially harmful impact. Another option is to interrupt the comment as it’s being said and redirect the conversation.
• Educate the speaker. Create a nonpunitive discussion by appealing to common values, promoting empathy, and increasing awareness of societal benefits. The speaker may become defensive and emphasize that their intent was not to cause harm. You must emphasize that, regardless of intent, the impact was hurtful. You may refocus the discussion with a simple statement such as, “I know you meant well, and…”
• Seek external support when needed. Addressing microaggressions can be emotionally taxing. Don’t be afraid to utilize community services, find a support group, or seek advice from professionals.

By virtue of being a neutral third party, bystanders who intervene may have greater success at explaining the impact of the microaggression. In doing so, the bystander also relieves the recipient of the microaggression of a burdensome response. In the above example, another provider in the PACU might pull the nurse aside later and say, “When you asked the junior resident if he was leading the code, you unintentionally indicated that he was the most experienced, which made it more challenging for the female senior resident to lead the response.” In this way, the “invisible” implication of the nurse’s words—that the male resident was the most knowledgeable physician in the room—is made visible, and the female resident is relieved of responding.

Microaggressions do not occur in a vacuum; context matters. Before employing these strategies, consider when, where, and how you address microaggressions. These strategies validate and support those on the receiving end of microaggressions, and thus counteract their deleterious effects. The onus is on us: we must not be silent.

The authors have nothing to disclose.

“Confidence comes from being prepared.”

—John Wooden

Hospital medicine is a field that requires a constant state of readiness and flexibility. With respect to patient care, constant preparedness is required because conditions change. This necessitates always having a backup plan, or Plan B. For example, your patient with a gastrointestinal (GI) bleed should have two large-bore intravenous (IV) catheters and packed red blood cells (RBCs) typed and crossed. If the patient becomes unstable, the response is not just doing more of the same (IV fluids and proton pump inhibitors); the focus shifts to your Plan B: call GI, transfuse blood, transfer the patient to the intensive care unit.

In contrast to clinical scenarios, there is often a lack of readiness to deal with rapid changes in workflow. Without a plan, efficiency decreases, stress levels rise, and both patients and providers alike suffer the consequences. Patients spending extended periods of time in the Emergency Department (ED) receive less timely services and often don’t benefit from the expertise that they would receive in inpatient units.¹ This is particularly true in an era in which many hospitals are experiencing higher overall volume and surges are more common.

Ideally, readiness should manifest as the ability to adapt to changes at the individual, hospitalist team, and leadership levels. Having a Plan B in the practice of hospital medicine is a focused exercise for anticipating future problems and addressing them prospectively. When thinking about a Plan B, the following are some steps to consider:

1. Identify Triggers. In the earlier example of the GI bleed, our triggers for Plan B would be a change in vitals or a brisk drop in hemoglobin. Regarding hospital workflow, the triggers might include low service or bed capacity or a decreased number of expected discharges for the day. Perhaps a high ED census or increased surgical volume will trigger your plan to handle the surge.

2. Define Your Response. At both an individual and service level, there are steps you might consider in your Plan B. On teaching services, this might mean prioritizing rounding on patients that you’re expecting to discharge so they’re able to leave the hospital sooner. For patients on observation status who are boarding in the ED for extended periods, there might be opportunities to safely discharge them with follow-up or even complete their work-up in the ED. There may be circumstances in which providers should exceed the usual service capacity and conditions in which it is truly unsafe to exceed that limit. If there are resources available to increase staffing, consider how to best utilize them.

3. Engage Broadly and Proactively. It is very difficult to execute a Plan B (or frankly a Plan A) without buy-in from your stakeholders. This starts with the rank and file, those on your team who will actually execute the plan. The leadership of your department or division, the ED, and nursing will also likely need to provide input. If financial resources for flexing up staff are part of your plan, the hospital administration might need to weigh in. It is best to engage stakeholders early on rather than during a crisis.

4. Constant Assessment and Improvement. Going back to our example of our patient with a GI bleed, you’re constantly reevaluating your patient to determine if your Plan B is working. Similarly, you should collect data and reassess the effectiveness of your plan. There are likely opportunities to improve it.

There are no textbook chapters or medical school lectures to prepare hospitalists for these real-world crises. Yet failing to have a Plan B is to surrender a tremendous amount of personal control in the face of chaos, to jeopardize patient care, and to ultimately forgo the opportunity to achieve a level of mastery in a field predicated on readiness.

“Confidence comes from being prepared.”

—John Wooden

Hospital medicine is a field that requires a constant state of readiness and flexibility. With respect to patient care, constant preparedness is required because conditions change. This necessitates always having a backup plan, or Plan B. For example, your patient with a gastrointestinal (GI) bleed should have two large-bore intravenous (IV) catheters and packed red blood cells (RBCs) typed and crossed. If the patient becomes unstable, the response is not just doing more of the same (IV fluids and proton pump inhibitors); the focus shifts to your Plan B: call GI, transfuse blood, transfer the patient to the intensive care unit.

In contrast to clinical scenarios, there is often a lack of readiness to deal with rapid changes in workflow. Without a plan, efficiency decreases, stress levels rise, and both patients and providers alike suffer the consequences. Patients spending extended periods of time in the Emergency Department (ED) receive less timely services and often don’t benefit from the expertise that they would receive in inpatient units.¹ This is particularly true in an era in which many hospitals are experiencing higher overall volume and surges are more common.

Ideally, readiness should manifest as the ability to adapt to changes at the individual, hospitalist team, and leadership levels. Having a Plan B in the practice of hospital medicine is a focused exercise for anticipating future problems and addressing them prospectively. When thinking about a Plan B, the following are some steps to consider:

1. Identify Triggers. In the earlier example of the GI bleed, our triggers for Plan B would be a change in vitals or a brisk drop in hemoglobin. Regarding hospital workflow, the triggers might include low service or bed capacity or a decreased number of expected discharges for the day. Perhaps a high ED census or increased surgical volume will trigger your plan to handle the surge.

2. Define Your Response. At both an individual and service level, there are steps you might consider in your Plan B. On teaching services, this might mean prioritizing rounding on patients that you’re expecting to discharge so they’re able to leave the hospital sooner. For patients on observation status who are boarding in the ED for extended periods, there might be opportunities to safely discharge them with follow-up or even complete their work-up in the ED. There may be circumstances in which providers should exceed the usual service capacity and conditions in which it is truly unsafe to exceed that limit. If there are resources available to increase staffing, consider how to best utilize them.

3. Engage Broadly and Proactively. It is very difficult to execute a Plan B (or frankly a Plan A) without buy-in from your stakeholders. This starts with the rank and file, those on your team who will actually execute the plan. The leadership of your department or division, the ED, and nursing will also likely need to provide input. If financial resources for flexing up staff are part of your plan, the hospital administration might need to weigh in. It is best to engage stakeholders early on rather than during a crisis.

4. Constant Assessment and Improvement. Going back to our example of our patient with a GI bleed, you’re constantly reevaluating your patient to determine if your Plan B is working. Similarly, you should collect data and reassess the effectiveness of your plan. There are likely opportunities to improve it.

There are no textbook chapters or medical school lectures to prepare hospitalists for these real-world crises. Yet failing to have a Plan B is to surrender a tremendous amount of personal control in the face of chaos, to jeopardize patient care, and to ultimately forgo the opportunity to achieve a level of mastery in a field predicated on readiness.

“Confidence comes from being prepared.”

—John Wooden

Hospital medicine is a field that requires a constant state of readiness and flexibility. With respect to patient care, constant preparedness is required because conditions change. This necessitates always having a backup plan, or Plan B. For example, your patient with a gastrointestinal (GI) bleed should have two large-bore intravenous (IV) catheters and packed red blood cells (RBCs) typed and crossed. If the patient becomes unstable, the response is not just doing more of the same (IV fluids and proton pump inhibitors); the focus shifts to your Plan B: call GI, transfuse blood, transfer the patient to the intensive care unit.

In contrast to clinical scenarios, there is often a lack of readiness to deal with rapid changes in workflow. Without a plan, efficiency decreases, stress levels rise, and both patients and providers alike suffer the consequences. Patients spending extended periods of time in the Emergency Department (ED) receive less timely services and often don’t benefit from the expertise that they would receive in inpatient units.¹ This is particularly true in an era in which many hospitals are experiencing higher overall volume and surges are more common.

Ideally, readiness should manifest as the ability to adapt to changes at the individual, hospitalist team, and leadership levels. Having a Plan B in the practice of hospital medicine is a focused exercise for anticipating future problems and addressing them prospectively. When thinking about a Plan B, the following are some steps to consider:

1. Identify Triggers. In the earlier example of the GI bleed, our triggers for Plan B would be a change in vitals or a brisk drop in hemoglobin. Regarding hospital workflow, the triggers might include low service or bed capacity or a decreased number of expected discharges for the day. Perhaps a high ED census or increased surgical volume will trigger your plan to handle the surge.

2. Define Your Response. At both an individual and service level, there are steps you might consider in your Plan B. On teaching services, this might mean prioritizing rounding on patients that you’re expecting to discharge so they’re able to leave the hospital sooner. For patients on observation status who are boarding in the ED for extended periods, there might be opportunities to safely discharge them with follow-up or even complete their work-up in the ED. There may be circumstances in which providers should exceed the usual service capacity and conditions in which it is truly unsafe to exceed that limit. If there are resources available to increase staffing, consider how to best utilize them.

3. Engage Broadly and Proactively. It is very difficult to execute a Plan B (or frankly a Plan A) without buy-in from your stakeholders. This starts with the rank and file, those on your team who will actually execute the plan. The leadership of your department or division, the ED, and nursing will also likely need to provide input. If financial resources for flexing up staff are part of your plan, the hospital administration might need to weigh in. It is best to engage stakeholders early on rather than during a crisis.

4. Constant Assessment and Improvement. Going back to our example of our patient with a GI bleed, you’re constantly reevaluating your patient to determine if your Plan B is working. Similarly, you should collect data and reassess the effectiveness of your plan. There are likely opportunities to improve it.

There are no textbook chapters or medical school lectures to prepare hospitalists for these real-world crises. Yet failing to have a Plan B is to surrender a tremendous amount of personal control in the face of chaos, to jeopardize patient care, and to ultimately forgo the opportunity to achieve a level of mastery in a field predicated on readiness.

“The world accommodates you for fitting in, but only rewards you for standing out.”

—Matshona Dhliwayo

Graceful self-promotion—a way of speaking diplomatically and strategically about yourself and your accomplishments—is a key behavior to achieve professional success in medicine. However, some of us are uncomfortable with promoting ourselves in the workplace because of concerns about receiving negative backlash for bragging. These concerns may have roots in our cultural and gender backgrounds, norms that strongly influence our social behaviors. Cultures that emphasize collectivism (eg, East Asia, Scandinavia, Latin America), which is associated with modesty and a focus on “we,” may not approve of self-promotion in contrast to cultures that emphasize individualism (eg, United States, Canada, and parts of Western Europe).¹ Additionally, societal gender roles across different cultures focus on women conforming to a “modesty norm,” by which they are socialized to “be nice” and “not too demanding.” Female physicians practicing self-promotion for career advancement may experience a backlash with social penalties and career repercussions.²

One’s avoiding self-promotion may lead others to prematurely dismiss a physician’s capability, competence, ambition, and qualifications for leadership and other opportunities. These oversights may be a contributing factor in the existing inequities in physician compensation, faculty promotions, leadership roles, speaking engagements, journal editorial boards, and more. Women make up over 50% of all US medical students, yet only 18% are hospital CEOs, 16% are deans and department chairs, and 7% are editors-in-chief of high-impact medical journals.³

So how do you get started overcoming cultural and gender barriers and embrace graceful self-promotion? Start small!

First, write a reference or nominating letter for a colleague. The exercise of synthesizing someone else’s accomplishments, skills, and experiences for a specific audience and purpose will give you a template to apply to yourself.

Second, identify an accomplishment with an outcome that educates others about you, your ideas, and your impact. Practice with a trusted peer to frame your accomplishment and its context as a story; for example: “Dr. X, I am pleased to share that I will present a key workshop on Y at the upcoming national Z meeting, based largely on the outcomes from a QI initiative that I developed and oversaw with support from my hospitalist team. We overcame initial staff resistance by recruiting project champions among the interdisciplinary team and successfully reduced readmissions for Y from A% to B% over a 12-month period.”

Third, consider when and how to strategically promote the accomplishment with your medical director, clinical leadership, department leadership, etc. Start out gracefully self-promoting in person or via email with a leader with whom you already have a relationship. If you want to share your accomplishment with a leader who does not yet know you (but may be important to your career), nudge a mentor or sponsor for an introductory conversation.

Finally, ask yourself the next time you are doing a performance review or attending a hospital committee meeting: Am I contributing to a culture in which everyone is encouraged to share their accomplishments? Which qualified candidates who don’t speak out about themselves can I nominate, sponsor, mentor, or encourage for an upcoming opportunity to increase cultural and gender representation? After all, paying it forward helps foster the success of others.

Graceful self-promotion is an important tool for personal and professional development in healthcare. Cultural and gender-based barriers to self-promotion can be surmounted through self-awareness, practice with trusted peers, and recognition of the importance of storytelling gracefully. A medical workplace culture that encourages sharing achievements and celebrates individual and team accomplishments can go a long way toward helping people change their perception of self-promotion and overcome their hesitations.

“The world accommodates you for fitting in, but only rewards you for standing out.”

—Matshona Dhliwayo

Graceful self-promotion—a way of speaking diplomatically and strategically about yourself and your accomplishments—is a key behavior to achieve professional success in medicine. However, some of us are uncomfortable with promoting ourselves in the workplace because of concerns about receiving negative backlash for bragging. These concerns may have roots in our cultural and gender backgrounds, norms that strongly influence our social behaviors. Cultures that emphasize collectivism (eg, East Asia, Scandinavia, Latin America), which is associated with modesty and a focus on “we,” may not approve of self-promotion in contrast to cultures that emphasize individualism (eg, United States, Canada, and parts of Western Europe).¹ Additionally, societal gender roles across different cultures focus on women conforming to a “modesty norm,” by which they are socialized to “be nice” and “not too demanding.” Female physicians practicing self-promotion for career advancement may experience a backlash with social penalties and career repercussions.²

One’s avoiding self-promotion may lead others to prematurely dismiss a physician’s capability, competence, ambition, and qualifications for leadership and other opportunities. These oversights may be a contributing factor in the existing inequities in physician compensation, faculty promotions, leadership roles, speaking engagements, journal editorial boards, and more. Women make up over 50% of all US medical students, yet only 18% are hospital CEOs, 16% are deans and department chairs, and 7% are editors-in-chief of high-impact medical journals.³

So how do you get started overcoming cultural and gender barriers and embrace graceful self-promotion? Start small!

First, write a reference or nominating letter for a colleague. The exercise of synthesizing someone else’s accomplishments, skills, and experiences for a specific audience and purpose will give you a template to apply to yourself.

Second, identify an accomplishment with an outcome that educates others about you, your ideas, and your impact. Practice with a trusted peer to frame your accomplishment and its context as a story; for example: “Dr. X, I am pleased to share that I will present a key workshop on Y at the upcoming national Z meeting, based largely on the outcomes from a QI initiative that I developed and oversaw with support from my hospitalist team. We overcame initial staff resistance by recruiting project champions among the interdisciplinary team and successfully reduced readmissions for Y from A% to B% over a 12-month period.”

Third, consider when and how to strategically promote the accomplishment with your medical director, clinical leadership, department leadership, etc. Start out gracefully self-promoting in person or via email with a leader with whom you already have a relationship. If you want to share your accomplishment with a leader who does not yet know you (but may be important to your career), nudge a mentor or sponsor for an introductory conversation.

Finally, ask yourself the next time you are doing a performance review or attending a hospital committee meeting: Am I contributing to a culture in which everyone is encouraged to share their accomplishments? Which qualified candidates who don’t speak out about themselves can I nominate, sponsor, mentor, or encourage for an upcoming opportunity to increase cultural and gender representation? After all, paying it forward helps foster the success of others.

Graceful self-promotion is an important tool for personal and professional development in healthcare. Cultural and gender-based barriers to self-promotion can be surmounted through self-awareness, practice with trusted peers, and recognition of the importance of storytelling gracefully. A medical workplace culture that encourages sharing achievements and celebrates individual and team accomplishments can go a long way toward helping people change their perception of self-promotion and overcome their hesitations.

“The world accommodates you for fitting in, but only rewards you for standing out.”

—Matshona Dhliwayo

Graceful self-promotion—a way of speaking diplomatically and strategically about yourself and your accomplishments—is a key behavior to achieve professional success in medicine. However, some of us are uncomfortable with promoting ourselves in the workplace because of concerns about receiving negative backlash for bragging. These concerns may have roots in our cultural and gender backgrounds, norms that strongly influence our social behaviors. Cultures that emphasize collectivism (eg, East Asia, Scandinavia, Latin America), which is associated with modesty and a focus on “we,” may not approve of self-promotion in contrast to cultures that emphasize individualism (eg, United States, Canada, and parts of Western Europe).¹ Additionally, societal gender roles across different cultures focus on women conforming to a “modesty norm,” by which they are socialized to “be nice” and “not too demanding.” Female physicians practicing self-promotion for career advancement may experience a backlash with social penalties and career repercussions.²

One’s avoiding self-promotion may lead others to prematurely dismiss a physician’s capability, competence, ambition, and qualifications for leadership and other opportunities. These oversights may be a contributing factor in the existing inequities in physician compensation, faculty promotions, leadership roles, speaking engagements, journal editorial boards, and more. Women make up over 50% of all US medical students, yet only 18% are hospital CEOs, 16% are deans and department chairs, and 7% are editors-in-chief of high-impact medical journals.³

So how do you get started overcoming cultural and gender barriers and embrace graceful self-promotion? Start small!

First, write a reference or nominating letter for a colleague. The exercise of synthesizing someone else’s accomplishments, skills, and experiences for a specific audience and purpose will give you a template to apply to yourself.

Second, identify an accomplishment with an outcome that educates others about you, your ideas, and your impact. Practice with a trusted peer to frame your accomplishment and its context as a story; for example: “Dr. X, I am pleased to share that I will present a key workshop on Y at the upcoming national Z meeting, based largely on the outcomes from a QI initiative that I developed and oversaw with support from my hospitalist team. We overcame initial staff resistance by recruiting project champions among the interdisciplinary team and successfully reduced readmissions for Y from A% to B% over a 12-month period.”

Third, consider when and how to strategically promote the accomplishment with your medical director, clinical leadership, department leadership, etc. Start out gracefully self-promoting in person or via email with a leader with whom you already have a relationship. If you want to share your accomplishment with a leader who does not yet know you (but may be important to your career), nudge a mentor or sponsor for an introductory conversation.

Finally, ask yourself the next time you are doing a performance review or attending a hospital committee meeting: Am I contributing to a culture in which everyone is encouraged to share their accomplishments? Which qualified candidates who don’t speak out about themselves can I nominate, sponsor, mentor, or encourage for an upcoming opportunity to increase cultural and gender representation? After all, paying it forward helps foster the success of others.

Graceful self-promotion is an important tool for personal and professional development in healthcare. Cultural and gender-based barriers to self-promotion can be surmounted through self-awareness, practice with trusted peers, and recognition of the importance of storytelling gracefully. A medical workplace culture that encourages sharing achievements and celebrates individual and team accomplishments can go a long way toward helping people change their perception of self-promotion and overcome their hesitations.