Adi Kumar
@adi_kumar1
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Neurosurgeon | Author | Co-Founder of - I help doctors thrive at work and at home
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Joined February 2022
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Surgical lessons from the Navy SEALs.
How breath control has kept me calm when 💩 hits the fan.
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How the NHS saved my daughter:
0800 - call to GP
0910 - call back
1000 - face to face, GP makes 3 in 10000 diagnosis
1130 - A&E then admission
1630 - consultant confirms diagnosis
2100 - specialised treatment costing £100/gram started
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Day 5 - discharged with medicines and follow-up in place
Today the same daughter attacked me with a dinosaur 🦖
Say what you want, this is a system worth fighting for.
Forever grateful to Broomhill Practice and
@RHCGlasgow
🙏🏽
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After 1400 operations and 8 years I completed my neurosurgery training.
In some ways I was obsessed.
Here are 9 lessons for the driven that I wish I knew when I was obsessively training and neglecting just about everything else:
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The over-confident surgeon causes harm from doing too much.
The under-confident surgeon causes harm from doing too little.
5 steps to building surgical confidence 🧵
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The over-confident surgeon causes harm by doing too much.
The under-confident surgeon causes harm by doing too little.
5 steps to building surgical confidence 🧵
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84% of health care professionals buy a coffee everyday.
Surgeons (ortho and general) drink more than most.
But coffee isn't all good.
Some Things You Need to Know About Coffee 🧵
(apologies in advance if I ruin your day)
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Surgeons in training - be aware of context switching, attention residue and decision fatigue.
Below is a near miss of mine I don't want you to repeat.
#neurosurgery
#training
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I performed over 1200 operation as a trainee surgeon.
These are the lessons I learnt over 8 years.
How to get the most out of theatre time as a trainee 🧵.
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As a neurosurgeon I've taught about the Dunning-Kruger effect.
But it isn't real.
If you think it is, this will be an eye-opener.
If you haven't heard about it before, you will still learn how false ideas can be useful and true ideas can be harmful. 🧵
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The operating room is a hostile environment for surgeons.
38% of surgeons are in pain.
87% if using an endoscope.
A primer on surgical ergonomics to save you suffering 🧵
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The operating room is a hostile environment for surgeons.
38% of surgeons are in pain.
87% if you use an endoscope.
THREAD - How I Cured My Shoulder and Leg Pain
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12 super boring things I do every day to perform my best as a neurosurgeon 🥱
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11 things I know at 35 I wish I'd know at 25.
For surgeons and doctors 🧵
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I'm a neurosurgeon in the NHS.
I've worked alongside more than 500 doctors in training and know when someone will be a great colleague.
Here are the 10 signs of bright future:
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I find training surgeons more difficult than operating.
Here's my system for being a better trainer during surgery 🧵
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Training a surgeon can be more difficult than operating.
Here's my system for being a better trainer in the operating theatre 🧵
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Being a surgeon is not just about cutting.
Over the last 10 years, the best I have worked with have highly developed "soft skills".
Here are the 9 that will make you standout 🧵:
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Surgeons in training - be aware of context switching, attention residue and decision fatigue.
Below is a near miss of mine I don't want you to repeat.
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As a surgeon, I love the 2-minute rule.
The 2-minute rule states that if a task takes 2 minutes or less, instead of planning to do it, do it immediately.
This helps surgeons for 3 reasons.
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How to get the most out of your theatre time as a trainee:
- Prep. Prep. Prep
- Read Widely
- Set Expectations
- Make Life Easy
- Be Predictable
- Do The Follow-Up
If you like this please RT and follow me for more
@adi_kumar1
DM me if you're a surgeon and want to learn more
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"Can I have 5 minutes of your time?" = "Can I have 28 minutes of your time?"
It take 23 minutes to regain your focus after being interrupted from a skilled task.
Be mindful of your attention and other's.
#meded
#neurosurgery
#medtwitter
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Here is a simple system I developed to stop this happening again:
Question from theatre team to referring doc - "Is this a life or limb-threatening referral?"
Yes-->Call on call consultant
No-->Please call back later
Don't know-->Speak to senior and follow above
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Training surgeons is stressful and operating is a privilege.
7 pieces of advice to get the most from your trainers 🧵
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Summary:
- Don't force things
- Keep perspective
- You are not your job
- Look for opportunity
- Don't be ruled by goals
- Don't compare to others
- Be interested, not passionate
- Balance hard work with hobbies
- Obsession is a two-edged sword
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Currently I find training surgeons more difficult than operating.
Here's my system for being a better trainer during surgery.
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@MarianHolling
Of course. It's written on the consent form. As an aside, how do you think surgeons get trained?
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How an orthopaedic surgeon turned GP/family physician changed my view of what it means to be a doctor 🧵.
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While scrubbing my hands I inhaled for 4 seconds, held for 4, breathed out for 4, held again for 4, then repeated.
This is box breathing which:
- reduces stress
- focuses your mind
- improves emotional control
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Being a surgeon is more than just cutting.
Over the last 10 years, the best I have worked with have highly developed soft skills.
Here are the 9 that will make you standout 🧵:
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Don’t admit defeat.
I didn’t get a neurosurgery interview first time round.
Second time I didn’t get a place again, but someone else deferred so I got their spot.
Now I’ve got a consultant job.
Keep going.
You’ve got to throw some punches if you want to connect.
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Summary:
• Box Breathing to focus
• Nasal Breathing to control stress
• Physiological Sigh to boost energy
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How I got my Consultant Neurosurgeon job.
(all the stuff they don't tell you on prep courses) 🧵
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1/ Prep. Prep. Prep more.
Know your patient. Know their pathology. Know their scans. Know their concerns. Know their hobbies.
You shouldn't be just turning up to cut.
This needs to be obvious.
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There is nothing more important than focussing on the patient on the table.
With the above system that focus is never broken.
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5/ Stop comparing.
Comparison is the thief of joy. Don't compare yourself to others, you can't see their journey up to that point in time, only external appearances.
Look at your own past performance remembering we have amnesia for highs and remember the rest.
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66% of doctors are worn out at the end of the day.
55% of medical students are emotionally exhausted.
You spent £46250 on medical school, but no one taught you how to rest.
How I recharge to make sure I can perform my best 🧵
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2/ Hard work is key.
But so is looking after yourself, your family, seeing your friends and having hobbies. As the years went by, time on my hobbies shrank.
You need space to space to recharge and refocus.
It's a marathon not a sprint.
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4/ You are not your job.
When you identify as "a surgeon" any external event shapes your self-belief. If you have a bad outcome you are a failure.
Instead do your best for patients. Monitor outcomes but do not make them the goal. Know your values as a person, not a surgeon.
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I hope you find this useful and you can learn from my mistakes.
If you enjoyed this thread:
1. Follow me
@adi_kumar1
for more of these
2. RT the tweet below to share this thread with your audience
Surgeons in training - be aware of context switching, attention residue and decision fatigue.
Below is a near miss of mine I don't want you to repeat.
#neurosurgery
#training
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Leaving work for the last time after nearly a decade at the
@INSNeurosurgery
Glasgow.
A very emotional day. For the first time I didn’t want to walk onto the wards. I knew saying goodbye would be hard, and it was.
Employees of the NHS will understand that unique bond forged
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3/ Obsession is a two-edged sword.
Obsession is a tool. Like any surgical instrument.
Pick it up when you need it. Learn how to direct it and use it.
But also learn when to put it down, relax, and be in the moment.
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3. Decision Fatigue
If you have been making decisions for a prolonged period of time without a break, like taking emergency referrals and operating, the quality of your decision making becomes worse with the passage of time.
This is known as decision fatigue.
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7/ Don't be passionate, be interested.
Passion is powerful but it's not magical. It will wax and wane. Instead follow your curiosity.
Give space to follow your interests, feed the ones that show promise, learn from the ones that don't.
The rest will take care of itself.
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2 inhales through the nose and 1 long exhale through the mouth.
The 1st inhale is deep and the 2nd is an extra "top up" to fill the lungs.
The double inhale "pops" small air sacks in your lungs (called alveoli) open.
This lets you take in more 02 and remove more CO2.
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1/ Focussing on one thing early in your career blinds you to opportunity.
After 3 years of being a doctor, neurosurgery was everything. It seemed like nothing else mattered, which was wrong.
Mentors will give you perspective by bringing you bak to the big picture.
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Everyday you make 3000 decisions.
50 of these will be wrong.
This is because of how your brain is wired.
Use Obama's Razor and others to reduce error 🧵
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2. Attention Residue
Attention residue is the penalty you pay for switching tasks.
The new task doesn’t get your full attention because you’re still partially focussed on the previous piece of work.
When taking the referral I'm thinking about the operation and vice versa.
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To be a great surgeon you have to be resilient.
But what is resilience?
Resilience is "the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress".
It is the ability to bounce back.
“Our greatest glory is not in never
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I have performed over 9600 hours emergency on call.
This is advice to myself back in 2014 🧵
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66% of doctors are worn out at the end of the day.
55% of medical students are emotionally exhausted.
You spent £46250 on medical school, but no one taught you how to rest.
How I recharge to make sure I can perform my best 🧵
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@SahilBloom
As a neurosurgeon I see the vagus nerve arising from the brainstem often. It does provide part of the critical balance of functions in your body, but with everything, stimulation via any method is not a panacea. The basics go far. Good food, rest, exercise and community.
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How I chose my surgical specialty using three numbers: 0 1 2
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How to speed up your medical training.
13 simple (and not taught) ways to reduce learning time 🧵.
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1. Context Switching
Context switching is our tendency to switch from task to another.
This is an essential ability for day to day functioning, but comes with a cost.
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6/ Keep perspective.
Few people care what operations you can do, or how many papers you have published.
The only people who truly care will be there even if you fail at all of those things.
The majority opinion doesn't really matter.
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My top 5 surgery books that have made me a better surgeon:
- Do No Harm
- Checklist Manifesto
- When Breath Becomes Air (keep tissues close by)
- Admissions
- Better: A Surgeon's Notes on Performance
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7/ You Have more Tools than a Scalpel
You will relieve more suffering with your words than with your hands.
You will spend more time talking to patients and their families than operating.
The impact will be just as great, if not greater.
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Resilience is a desired character in a surgeon.
But surgeons are just as frail and vulnerable to stress as the general population.
My thoughts on being a resilient surgeon 🧵
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2/ Read Widely
Read up on the pathology. Read on the anatomy. Read on the approach.
Watch videos on YouTube.
Come with questions to demonstrate your reading.
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4. Systems Error
The imaging system I use has the flaw that it will not automatically load the most recent scan.
Because of the context switching and decision fatigue I didn’t notice I was looking at an old scan.
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After 8 years and 1400 operations, I completed my neurosurgery training.
In some ways I was obsessed.
Here are 9 lessons I wish I had known when I was obsessively training and neglecting just about everything else:
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Surgical lessons from Brazilian Jiu Jitsu.
How fighting helped me complete neurosurgical training 👊🏽
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Summary:
You have more tools than a scalpel
Choose your colleagues wisely
You won't always find a reason
One is none and two is one
Regression to your mean
Don't worry so much
No one is in charge
You can be lethal
Effecting change
Don't compare
Write clearly
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Summary:
- Caffeine improves mood, wakefulness and cognition
- It can have negative effects for healthcare professionals
To prevent side effects:
- Delay morning intake
- Take a week off coffee once in a while
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5/ Quiet your ego.
Smart people don't tell you how smart they are.
Confident people don't tell you how confident they are.
They know themselves and don't have to tell the world.
They best still doubt themselves a little.
It keeps them sharp and keeps their egos in check.
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"Can I have 5 minutes of your time?" = "Can I have 28 minutes of your time?"
It take 23 minutes to regain your focus after being interrupted from a skilled task.
Be mindful of your attention and other's.
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6/ Do the Follow-Up
The case doesn't end in theatre. Do the op note, the MDT referral, the post-op scan request and the discharge letter.
Demonstrate you are mature and are acting like a consultant.
Because you will be before you know it.
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4/ Make Life Easy
Make your supervisor's life easy.
If they like a certain marker pen, get it. If they like music, put some on. If they like a specific microscope, book it.
If your supervisor doesn't need to think about these, they will have more bandwidth to train.
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Summary of surgical confidence:
- Be you
- Lower the bar
- Raise the floor
- Quiet your ego
- Trust your training
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I have delivered over 10,000 hours of emergency neurosurgery care.
Advice to myself back in 2014 🧵
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The physiological sigh will:
- reduce stress levels
- reduce blood pressure
- increase oxygen intake
- increase carbon dioxide removal
It also helps you recover after a hard shift at work by activating your parasympathetic nervous system for rest and recovery.
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Surgical training is a marathon not a sprint.
Work hard, but also look after yourself, your family and friends.
Consistency will beat intensity in the long run.
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6/ Don't Worry so Much
Worrying about the future is like praying for bad luck.
Don't worry so much.
The tough times that do come, are not the ones you expected.
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8/ Don’t but ruled by goals.
Goals are necessary but not sufficient for progress.
Your goals will slowly shift from aspirational to anchors.
Goals can be the very things that may motivate and push you forward, but can ultimately weigh you down.
Enjoy the process.
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9/ Don’t force things.
You are going to experience great highs and some depressing lows.
You’ll question why you chose this job.
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The SEALs have a fierce reputation.
80% of people do not survive the 1st week of training.
Their training seperates those who can handle stress, from those who can't.
Breath control is a key part of their training.
But why?
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Beware of sleep inertia 😴.
It will slow your reaction time, thinking and performance. 🧵
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1/ You Can be Lethal
You are most dangerous when your skill set outstrips your experience.
This is towards the end of your training as a surgeon.
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I have performed 43 operations that have lasted more than 10 hours each.
When you know there is a big day ahead, you must prepare your mind and body.
How to prepare and succeed with any big challenge 🧵
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11/ Don't Compare
Comparison is the thief of joy.
Social media, word of mouth, rumours will make you compare yourself to a curated ideal of others.
The only person worth comparing yourself to is your past self.
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5/ Be Predictable
While operating, be predictable.
Don't drill down deeply in one spot then skip to another area.
Drill "like you're painting", slowly and from side to side.
This makes it obvious where you are going next and therefore predictable.
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2/ Raise the floor, not just the ceiling.
Your performance will regress to your average.
Don't focus on the extremes of great days and bad days.
Know your average and aim to improve on this everyday.
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But that knowledge does not mean you have the experience of how best to use it.
One of the most difficult skills to learn is when not to operate, even if you think you can.
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1/ Physiological Sigh
Towards the end of a busy week and busy on call, my energy levels were low.
I had to perform a craniotomy for trauma at 4am.
Instead of more coffee, I did this breathing pattern instead.
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In 1944 the CIA made The Simple Sabotage Field Manual.
A step by step guide to sabotage any organisation.
Read the steps below.
Then do the exact opposite 🧵
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When external goals supersede embracing the process, you will tread on your own values.
Anxiety, stress and questioning yourself will follow.
All you can do is work to give yourself the opportunity to succeed and see what happens.
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"Resilience" is a desired character in a surgeon.
But surgeons are just as frail and vulnerable to stress as the general population.
My thoughts on being a resilient surgeon 🧵
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How I get in a deep work state.
1 - Binaural beats 40Hz. 10 minutes prior.
2 - Phone on flight mode.
3- Warm up. Easy tasks like email.
4- 90 minute timer and start main work. Circadian rhythms run in 90 min cycles.
5- Decompress. Walk, chat, read.
Repeat.
#productivity
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10 signs of a great colleague and bright future:
- Honest
- Right Attitude
- Doesn't Bad Mouth People
- A Team player
- Communication
- Not a "yes man/woman"
- Prepared
- Curious
- Asks for Help
- Cares for Patients
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Caffeine is a neuro-stimulant.
It blocks adenosine in your brain promoting wakefulness.
But caffeine does more than wake you up.
It also improves mood and cognitive performance by decreasing reaction time and increasing visual processing speed.
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1. Follow me
@adi_kumar1
for more of these
2. If you learnt something, RT the tweet below to share with your friends and colleagues
Surgical lessons from the Navy SEALs.
How breath control has kept me calm when 💩 hits the fan.
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3/ Set Expectations
Is this the first time you are doing the case? Or the 30th? Do you expect to do the approach only, or the entire case?
Discuss the day before surgery so you are both on the same page.
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4/ No One is in Charge
You will have your wizard of Oz moment.
At some point, you will pull back the curtain hoping to see the magician running the system.
You will be disappointed.
What you will see are many separate groups, doing their best to keep the ship from sinking.
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I was performing an out of hours emergency operation when a referral came. The referring doctor was adamant that they wanted to speak to me.
I was at the stage of training where I would stop operating to take referrals.
I no longer do this.
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