[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm very excited to be speaking with Dr. Allison Osmond. Dr. Allison Osmond is an Assistant Professor of Pathology and Laboratory Medicine at the University of Saskatchewan. Dr. Osmond completed residency in Anatomic Pathology at Western University in London, Ontario, Canada in 2015, followed by a Surgical Pathology Fellowship at Western with a focus in Gastrointestinal Pathology. She then worked in a General Anatomical Pathology practice for one year and then completed Dermatopathology Fellowship at the University of Toronto in 2018. Dr. Osmond has a keen interest in digital pathology and teaching dermatopathology to residents and medical students at the microscope and, in particular, via the global #dermpath Twitter community. And you can find her cool posts with lots of emojis on Twitter @redsnapperpath. And a link to that will be in the show notes.
[00:00:54] Allison Osmond: Love the Path Twitter.
[00:00:55] Christine Ko: So my first question to Allison is, can you share a personal anecdote with us that tells us a little bit about you? That's not in that bio that I just read off.
[00:01:05] Allison Osmond: Yeah, so I would probably say I'm from Newfoundland. It's a beautiful island off the east coast of Canada, so if you're able, definitely try to visit if you can. And I'd also say I'm a big basketball fan, played for a number of years. But now I just am relegated to the couch or the stands because I ended up rupturing, not one, but both Achilles tendons at different intervals, so...
[00:01:27] Christine Ko: Oh, no.
[00:01:28] Allison Osmond: Yeah. So that was a bit of a bummer. But my first one was the same time as Kobe Bryant ruptured his, so I was really keeping good company for that one.
[00:01:35] Christine Ko: That is good company. I'm sure your skills were comparable as well.
[00:01:39] Allison Osmond: Definitely not.
[00:01:40] Christine Ko: You have some experience with dialectical behavior therapy. Could you tell us a little bit, because I'm really not that familiar; I've just heard a little bit from David Caruso about dialectical behavior therapy. Could you tell on dermpath, derm, sort of physician level, what dialectical behavior therapy is?
[00:01:58] Allison Osmond: Yeah. I'm not a content expert, that's for sure. I did encounter it in a course for burnout. DBT, abbreviated, will tackle a lot of concepts. Mindfulness and distress tolerance, emotion regulation, and interpersonal effectiveness, which you talk a lot about in your podcast. And one of the bigger concepts is this idea of the different states of mind: wise mind, rational mind, and emotion mind, which I believe another speaker that you had on had mentioned this in one episode, right?
[00:02:26] Christine Ko: Yes. David Caruso did.
[00:02:28] Allison Osmond: These are concepts that are good for listeners to take away and think about. So rational mind is like when logic prevails, it's in the driver's seat. And an example would be like when we're measuring Breslow on a melanoma. It's rigid in its own way, and it's unidimensional. And then there's emotion mind, which is emotion-based decision making, which, I think probably for the most part, this doesn't enter sign out a lot, which, or at least if it does, we're probably running into trouble. But it definitely bleeds into departmental meetings sometimes and when you go home. Again, that's kind of a unidimensional state. Wise mind is the union of these two states of mind. I think of wise mind as something that propels intuition and gut feeling.
[00:03:15] Christine Ko: That's cool. So do you find that, with practice, you can channel that wise mind when you're signing out?
[00:03:22] Allison Osmond: I think to really finesse wise mind, I notice it in retrospect. I have to be more proactive in identifying, like, I'm probably too much in emotion mind now, so I need to step back... intuition is hard to channel. It just happens.
[00:03:37] Christine Ko: That's true. Intuition just pops off for me. I liked how you said that the rational mind is like Breslow depth when we're trying to measure because there's really no emotion in math. If you're just literally measuring something, that's math, that's rational, there should be a measurement. But I think emotion, not literally, but it comes into Breslow depth too, because now we round up. It's still math to round up, but also, where do you choose to measure from? I know we're supposed to do from granular layer, et cetera, but sometimes you don't really have a granular layer for various reasons.
[00:04:09] Allison Osmond: For sure. I think we all like to say we're all very rational, but in its most pure form, it's very rigid.
[00:04:16] Christine Ko: Yeah.
[00:04:16] Allison Osmond: If you're just exclusively rational. Lends to really black and white thinking.
[00:04:20] Christine Ko: You mentioned dialectical behavior therapy, or DBT, is useful in managing burnout. Can you explain that a little more?
[00:04:29] Allison Osmond: There's a lot of resources for physicians to read about burnout. Two big things are key in burnout. The first one is decision fatigue. That's a big component of burnout, and we're not really forced to think about the decisions we make until our mind is hampered, and we can't, really make decisions like we used to. How am I going to demonstrate decision fatigue? I took a tally of the number of decisions that I made in one case, from picking up the slide all the way to sign out from a preanalytic and a postanalytic, and I didn't take any decision for granted either. Do I need levels? Am I gonna order PAS? Am I going to bring it to rounds? And so on.
[00:05:10] Christine Ko: Yeah.
[00:05:10] Allison Osmond: So with that one case, I was hitting up to 50 small decisions. Now, with more complex cases, you can run up to a hundred. Let's say, on average, we read about 70 cases a day. So that works out to a range of 3,500 to 7,000 decisions.
[00:05:29] Christine Ko: Wow.
[00:05:29] Allison Osmond: And then we multiply that by five days a week, and then we're running 17,000 to up to 40,000 decisions. And that's just at our desks. I'm not talking about emails, meetings. So it's a lot of rational mind. I can't even tap into the decisions that a wise mind and intuition's doing.
[00:05:48] Christine Ko: Yeah.
[00:05:49] Allison Osmond: So for me, as a young career dermpath, less than five, 10 years experience, I was well trained. I moved around a lot in different labs in the first year and when I landed on a spot, it was great because the cases were plentiful, but it was also like a solo gig. The volume was almost double my peers with similar experience, and the practice wasn't really set up for subspecialty signout in addition to academic commitments and so on. And it really became an unwinnable situation Monday to Friday. Just a perfect storm. When I was struggling on this, I just couldn't even decide what I was going to have for dinner that night. I knew that I was encroaching on a territory that was just not myself and it was just very unsettling.
[00:06:14] Christine Ko: Yeah.
[00:06:14] Allison Osmond: And medicine really normalizes and sometimes even emphasizes overwork. As a young career dermpath, you can experience a lot of shame. So my advice would be to just keep in mind that in emotion-prevalent state of mind, you are making decisions through a warped view. Its tentacles really touches everything in your home and personal life. In those days, job offers came and went, and I couldn't even make decisions on even bigger things.
[00:06:48] Christine Ko: Thank you for sharing that. You said so many things that resonated with me. I think you're absolutely right that the culture of medicine does expect over work. I recently learned a definition of shame, which is that you can feel shame when you fall short of a standard. I think that makes perfect sense that when we do recognize, and I think at least both of us are in agreement, that the culture of medicine, as a whole, is a standard of overwork.
[00:07:14] Allison Osmond: Yeah.
[00:07:15] Christine Ko: Then to feel like you're not matching up to that standard does actually create shame. I have experienced that as well, for sure.
[00:07:22] Allison Osmond: One thing, as you're talking here, I'm remembering one thing they talked about was the difference between guilt and shame. People will mistake one for the other.
[00:07:29] Christine Ko: Yeah.
[00:07:29] Allison Osmond: I always remember guilt has a you in it. It's from you. Whereas shame is an external standard. It's imposed on you from the outside.
[00:07:38] Christine Ko: Yes. I really only recently started delving into shame. It's defined by cognitive psychologists, social psychologists, as a social emotion. So you're exactly right. It is actually induced upon us in a social manner. Shame is a social emotion.
[00:07:56] Allison Osmond: They often feel the same inside.
[00:07:58] Christine Ko: Yeah.
[00:07:58] Allison Osmond: That's why it gets confusing sometimes.
[00:08:00] Christine Ko: That's a really good point, too. Yeah. They can feel the same to us inside. Emotions researchers have all these definitions of shame versus guilt and as lumpers, it's okay, fine. Like they can be the same thing, but I think to sometimes have more of an understanding of how I'm feeling, it is useful to see the difference.
[00:08:17] Allison Osmond: Yeah.
[00:08:17] Christine Ko: It really was eye opening. It was eye opening to me to think of shame, 1) as a social emotion imposed by some other, even if it's an imaginary other in my own mind, and 2) that I could potentially feel shame whenever I fall short of a standard, even if the standard is unreasonable.
[00:08:32] Allison Osmond: Yes. Yeah, that's also very important too. Yeah, exactly. It doesn't protect you. It's just a standard whether it's reasonable or not.
[00:08:41] Christine Ko: What we're talking about, as you mentioned too, definitely touches on emotional intelligence. I can be more emotionally intelligent by using the things that I feel. If I do feel shame, to name it, Oh, I'm feeling shame. What standard do I think I'm falling short of here? Is it a reasonable standard or an unreasonable standard?
[00:08:57] Do you use emotional intelligence in work or home life?
[00:09:00] Allison Osmond: Foster emotional intelligence in a real way.... I think unfortunately, a lot of times it becomes performative, right? We say the buzz words, but we don't really follow through with empathy, reflection, and like carrying it to the next time. I try to keep that in mind and to look for trends in myself. You can't always expect it from others, but you can keep trending yourself, right?
[00:09:24] I think at the heart of emotional intelligence, we're really trying to see the whole person, not only in other people, but also in ourselves. My friends and family really extended generosity to me in burnout and when interactions are suboptimal, I try to remember that and seeing people from the 3D, the 4D, the infrared, and not just not from what is scattering from the surface.
[00:09:49] Christine Ko: Yes. Yeah. To try to have a different perspective. Put yourself in their shoes. Give them grace, especially if they've given you grace in the past.
[00:09:57] Allison Osmond: It's always a work in progress. I have some great friends that were very generous with me, so they helped me see these things. It's not something I came to independently.
[00:10:08] Christine Ko: Yeah. I think relationships are important. I spoke to Michi Shinohara about burnout. It is a system problem. So even though I might feel ashamed if I feel burnout, I shouldn't, and no one should, because it really means that the system is usually being unreasonable, setting an unreasonable standard. So even though she said it's a system problem, you don't want to just let people drown. Individually we can hopefully try to help ourselves or have relationships that help us because the system is not seeming to be able to change anytime soon or quickly. Relationships where I feel safe and I feel like someone sees me and hears me, that is really helpful.
[00:10:49] Allison Osmond: Yes. And it's hard because, if you try to speak up in young career, and no one's really taking you seriously, it's difficult. It's a hard place to be.
[00:10:59] Christine Ko: It is hard. Yeah. It is really hard. Do you have any final thoughts?
[00:11:03] Allison Osmond: So I have a couple final thoughts. The first one, I just want to say, I'm a hundred percent fangirling, up in Canada here, of Dr. Ko. Right. I think it's amazing that you're using your privilege to do something like this, right? Privilege begets privilege. I think it's just great that you're doing that. And disclaimer, I'm not a content expert on emotional intelligence in any way. And in a lot of ways, the clouds of burnout is still leaving my mind. So if I can somehow help one early career dermpath, then I would've done my job. I've shouted out to my family and friends, but also got to shout out two dermpaths that joined the practice here, Dr. Caitlin Campbell, on Twitter, and Dr. Glenda Wright, who make the job enjoyable every day.
[00:11:51] Christine Ko: Oh, that's awesome. I'll have to put a link to Dr. Campbell, to her Twitter as well, in the show notes. Thank you for spending the time to do this.
[00:11:59] Allison Osmond: Thanks for creating a safe space.
[00:12:01] Christine Ko: I'm totally, sending fan vibes back.
[00:12:03] Allison Osmond: That's quite the compliment.
[00:12:06] Christine Ko: Thank you.
[00:12:07] All right. Thanks.
