On Easter: Separate and Unite

Posted on April 21, 2019 by Catherine Cheng, MD

What does Easter mean to you?

It occurred to me as I sat in the second pew today, coming to church on Easter labels me. I declare myself Catholic on this occasion, in this place. I separate myself, in a sense, from all who are not Catholic or Christian, from all who do not celebrate. You might consider that I do this every Sunday at church, or every time I say I’m Catholic. But on Easter it feels more intense, because this mass is all about the definition of Christianity—He died for us—we hold this to be true (I still have questions about that, actually) and that is what makes us Christian. I apply this label to myself by my attendance at this mass.

I generally dislike being labeled, because of the assumptions that inevitably and automatically accompany labels of any kind. You are Catholic, therefore you must be pro-life and thus anti-woman (I am pro-choice). Your church is full of pedophiles and those who abet them; your religion, and you as an extension, represent the worst kinds of repression of the reality and diversity of human expression (if you think this please read about Father James Martin). You are Chinese, you must be so smart and have a Tiger Mom (I am so smart but I don’t attribute it to being Chinese, and my mom is not Amy Chua). You are a doctor in executive health, you must have done it for the money (this one slapped me recently, and I still seethe a little over it).

I have attended my church for 28 years this fall, starting my freshman year in college. I was confirmed here, my children were baptized here, and I would have been married by the priest here, had it not been New Student Week that year. I have so many friends here, from the couple who sponsored me for confirmation to the woman who ran the nursery where both of my kids played, to the director of the prison ministry who has kept the pencil record of my kids’ heights on the wall in his office. I return to this community not for the ‘body and blood’ mass parts, which I could get at any Catholic church. It’s how the people here put their faith into action that I admire—seeking connection across diversity, holding space for differing viewpoints and discoursing with respect and compassion. Next month there will be a dialogue on the Ten Commandments led by our pastoral associate and a Northwestern campus rabbi, entitled, “The Big 10.”

I consider myself not religious at all, rather faithful and spiritual, and this is where I practice. So while I separate from non-Christians this Easter, I unite with this particular Catholic tribe. And let me be clear: separating into tribes is a GOOD thing. Humans are wired for belonging and shared identity. Support from those we identify with and relate to is essential for survival and thriving, especially in chaotic and uncertain times like now.

But it is in exactly such times when we must be wary of over-identifying with those we perceive as similar to ourselves. Separating (or sorting, as Bill Bishop calls it) ourselves by religion, ideology, profession, or any other in-group carries risks for us all. As I looked around the chapel today, I saw a widely diverse group. Most people were white, many at least a generation older than I. But there are always college students here, bringing balance, which I love. I see also families like mine, our children growing up as members of the community, making it a whole of many assorted parts. No doubt we are not all of one political persuasion, and we each have our own reasons for whatever opinions and positions we take. We must not assume that just because we attend the same church, in this little building or the Catholic church of the world, that we are all the same, or wholly different from those outside of our church or faith.

As we unite as Christians this Easter, then, separating ourselves from ‘non-believers,’ what is the best object of our spiritual focus? When we think of ourselves in terms of this religious tribe, how does it impact our identity and relationships in the tribe of humanity?

What are we called to do with this faith of ours, how are we meant to best manifest it here on Earth?

I hear Brennan Manning’s words in my mind all the time, like a warning:

The greatest single cause of atheism in the world today is Christians who acknowledge Jesus with their lips and walk out the door and deny Him by their lifestyle. That is what an unbelieving world simply finds unbelievable.

By the end of mass, I decided that if I choose to accept this ‘religious’ label, oversimplified and overgeneralized as it is, then I must represent it well. I must not personify the corruption and hypocrisy that so many identify with Christianity—I must demonstrate the opposite. My faith in action must be driven first and always by love, and never by fear, never by suspicion. If I can pull this off, then separating myself as Catholic or Christian serves wholly to unite me with all of humanity, because that is what my faith, and what I believe the best of all faiths, calls us all to do.

Reconnecting to Mission, Patients, and Colleagues

Posted on April 14, 2019 by Catherine Cheng, MD

What’s the most personally fulfilling aspect of your work? In times of uncertainty, threat, and transition, what holds you up?

This past week, I had the privilege of standing alongside giants in the fight against physician burnout. In a series of presentations at the annual meeting of the American College of Physicians (ACP), we did our best to acknowledge and validate the current state of physician burnout (about half of all physicians in all specialties report at least one symptom), and then present as many strategies to reduce it as time would allow. We showed how changes in workflow, task distribution, and technology, such as pre-visit labs and scribes, have been shown to improve physician satisfaction, team morale, and patient experience. My role was to attempt to inspire my fellow internists to claim their individual agency, model a culture of wellness, and advocate for systems change in their home institutions.

The content felt dense but manageable, and the audience appeared engaged. Our colleagues from all around the country approached us afterward to clarify studies of efficacy and ask about local representatives for advocacy in the ACP. In the end, I think we achieved our primary objective of having most attendees leave with just a little more hope for our profession than they came in with.

Over the four day conference, however, what consistently grounded me in professional mission and meaning, not only in our own presentation but in others, were the personal stories. That is how we humans relate to one another, after all—through narratives. And connecting to mission and colleagues is key to maintaining a healthy and productive workforce, physician or otherwise.

Our attendees participated in two practices that I’ll share here. Both were “Pair and Share” activities, meant to stimulate reflection both internally and externally.

Who In Your Life Really Changed You?

First we asked our colleagues to think of a patient who changed them, how, and to what end. I know there have been many patients who changed me, but I always think of one particular woman. She was middle aged, obese, diabetic, depressed, and severely disabled from osteoarthritis. She lived alone and had a sparse social network, and her life partner had died unexpectedly a few years before I met her. At every visit we struggled through the same fundamental challenges of weight loss, glucose control, and pain management. How could she take her diabetes medications more regularly? How could we control her pain without having to take opioids every day? How else could we manage her depression, as some of the medications were raising her blood sugar? She may have cried at almost every visit; wailing was not uncommon, and once she even vomited from cumulative distress. Our relationship was good overall. I overcame my impatience with her non-adherence to the treatment plan as I understood her life situation better. But for four of the five years we knew each other, I saw few if any indicators that her thought, emotional, and behavior patterns would change.

Then things started to turn around. She started coming consistently to appointments, no more no-shows. She got online and found a community center that was accessible by bus. She connected with a knitting group and started going to art fairs to sell her creations. She started taking her medications more regularly, and lost enough weight to have her knee replaced. By the time we parted ways, she had transformed from a weeping victim of circumstance to a woman with agency, self-efficacy, and goals, dammit! And most of this had nothing to do with me. I simply had the privilege to witness and support her intrinsic revolution. From her I learned what perseverance looks like; I learned about hope and self-redemption; I learned that I should never make assumptions about anybody’s future.

Who Supported You in a Time of Vulnerability?

They said do the hardest thing that you know you don’t want to do for a living as your first rotation. So I chose surgery. In July of my third year of medical school, my days started around 5:30am and could end the next night at 10pm if my team was busy post call. Most faculty physicians were kind and wise, or at least non-abusive. Some, however, not so much. What buoyed me most through that rotation was always the support and protection of the residents on my team. I would watch them get abused by our attendings, but that sh*t never rolled downhill when the boss left the room. I did not fully realize until years later what a gift that was and how much it spoke to the character of these men (they were all men). This was in the 1990s; verbal abuse of medical students and snide comments about one’s appearance, gender, and just about everything else were simply to be expected. But my favorite residents always pulled me aside and asked how I was. They always made sure I felt confident about my role on the team, and they taught me basic skills with conviction and encouragement. As I was about to insert a patient’s bladder catheter in the operating room, my elder brother in training told me firmly, like he really believed I could do it, “Don’t be afraid, hold it (the penis) like a hose.”

As we did this reflection exercise at the meeting last Wednesday along with our audience, I was so moved by these memories that I looked up one of my old residents that night and sent him a thank you card. I bet he won’t remember at all who I am, but he will hopefully feel validated that he is in exactly the right position now as program director of a surgery residency.

*****

Recalling stories like these, and then sharing them with a person who truly listens, receives them generously, and simply helps you hold them (that was the instruction to the group—when it’s your turn to listen just do that, no interruptions, no jumping in), reconnects us to our calling in medicine. It’s not just about the patients or the science. It’s about all of the relationships and how we tend them.

We will not solve the immensely complex problem of physician burnout overnight. It will take a concerted effort at all levels of healthcare, and physicians cannot and will not do it alone. And it’s not that we are stoic, arrogant, and somehow intrinsically flawed, and thus dissatisfied with our work and leaving the profession in record numbers. It is a systems problem, no question. And, while we call our congressional leaders and professional advocacy groups to change policy, while we lobby our hospital administration to hire more support staff and move the printers closer to where we do our work, we can all take a few minutes each day and reconnect to the core meaning and purpose in that work. Let us all remember a cool story and share it today.

Pain and Desperation

Posted on April 7, 2019 by Catherine Cheng, MD

When was the last time you used any narcotics? I think I took some of my mom’s cough syrup with codeine over a decade ago, when I felt like I might actually cough up a lung. Before that it was one dose of Darvocet after having four impacted wisdom teeth extracted at age 18. I don’t really remember much after swallowing the pill and lying down on the sofa. I was given multiple opioids during knee surgery last year, but needed only Tylenol and Advil afterward. Looking back on the post I wrote about that experience, I realize even more how I was influenced by this piece in the New York Times just a month before my surgery. In it the author is reminded that pain serves an essential purpose, and it’s better that we not necessarily seek to obliterate it at every turn.

* * * * *

Four or five times in the last two weeks, I have received calls from local pharmacies to confirm opioid prescriptions that I did not write. They were all paper prescriptions for patients I have never met, caught by astute pharmacists who suspected fraudulent activity. This is the first time it has happened to me, and I know many of my colleagues have experienced the same. Pharmacies in the area have now flagged my name and license number, and they know not to fill any controlled substances without direct confirmation from me.

What a morass. How did we get here? It’s a rhetorical question, really, but not a simple one by a light year. When I started my training, we were taught to consider pain the ‘5^th vital sign.’ Every patient assessment included the cartoon face pain scale. Anesthesiologists’ prioritized rubrick for pain control started with long acting opioids around the clock, then regular anti-inflammatories if no contraindications, then short acting opioids as needed for breakthrough pain. In the hospital I never questioned this method, especially since I almost never interacted with these patients after discharge and was oblivious to follow up issues.

It was not until I started in practice that I experienced the multidimensional challenge that is pain control and opioid prescribing. After 15 years I am still learning the layers of complexity, unique for every patient, and I see that even if we understand it (which I think we do not), most of us feel helpless to address it.

The pharmacist I spoke to today told me that his store’s standard procedure is to inform the patient that the prescription was proven to be fake, advise the patient not to attempt such an act again, and let them know that the prescriber is aware and the police will be contacted. It was that last part that made me pause. Because even as I intend to file a police report (as advised by my institution), the answer to the problem is not, in my opinion, rounding up patients with chronic pain and throwing them in jail. In order of importance, I think the opioid crisis is first a social, then a medical, and only then, a criminal problem.

* * * * *

Increasingly, we have become a society of immediate gratification and entitlement. We want and expect a magic pill for and complete relief from whatever ails us—because it’s the twenty-first century for crying out loud, how could we not have that already? Also, medicine has become increasingly transactional. We, patients and physicians alike, experience ‘care’ in predetermined packets of protocol and procedure, and spend considerably less time in conversation, education, expectation setting, and actual caring. The advent of the internet has accelerated this immediate gratification expectation. It also gives many of us an illusion of connection through social media, when in reality, we are actually less and less connected to one another.

Pain results from myriad causes. We all have varying thresholds for feeling and tolerating pain, which vary themselves depending on circumstances, mindset, expectation, and meaning making (think childbirth versus bike accident). There are so many factors that impact our pain experience, including dehydration, sleep deprivation, low mood, and emotional and/or mental stress. Loneliness, depression, anxiety, sleep disruption, suicidality, and substance abuse are all on the rise. And all of these conditions lower our thresholds for pain and the harm it does to us.

For many, opioids are indeed the immediately gratifying magic pills. But the magic wears off faster and faster, and both pain and the desperation for relief accelerate in the wake of short and long term withdrawl. As physicians, we feel an intense desire to alleviate suffering. Once a patient has experienced the profound relief (both physical and psychological) from opioids, it feels cruel for us to withhold them, even when we understand fully their risks and the long term harm they cause. And we have less and less time to explore with and educate patients about adjunct pain management practices, such as mindfulness, biofeedback, and movement. Everybody feels despairing and impotent, and this drives people to do things they might not otherwise do, like make a fake prescription for hydrocodone and try to get it filled.

I know there are real criminals out there, people not really in pain, who do this to make money—to take advantage of people in real pain. I don’t know who’s who. But the story I tell myself is that this is not most people. What we need is a stronger infrastructure to address chronic pain at multiple levels—individually, in community, with policy, and culturally. As I write this, even as a physician with a leadership title, I feel powerless and a little hopeless.

But maybe a good start, at the individual level, that we can each do the next time we look ourselves in the mirror or meet another human being on the street, is to just exercise a little compassion and generosity. I assume that those patients presenting the fake prescriptions, if they are real patients, are not criminals at their core. Pain makes us do unthinkable and unbelievable things. I hope we can all help one another find better sources of relief and support.

The Beauty of Repeating Patterns

Posted on April 1, 2019 by Catherine Cheng, MD

Last week I wrote about our stories and how they perpetuate despite their dysfunction. Tonight I consider patterns and how they also resist change—for better and for worse.

We had a wedding in the family recently. Aunts, uncles, and cousins flew in from all over the country to attend and celebrate. I have graduated to the parents’ generation at most weddings now; it feels strange and natural at the same time. ‘Kids’ these days do things very differently in some ways (everything was online—no paper!), and exactly the same in others (there was a beautiful dress, an aisle, rings, kissing, and I saw her wear something blue). Sitting with my fellow zhang bei (elder generation), I recalled when each of us got married, all on the order of 15-20+ years ago. Like the happy couple, we were all young, most of us were thinner, and we had darker hair. Our Chineseness and its influence on nuptial activities felt a little heavier than for the next generation, and yet that cultural heritage still shines through today—that makes me proud.

How will the new couple choreograph their marriage dance? When the rest of us started out, could we have predicted our tangoes to look and feel how they do today? Part of me says yes, absolutely—just look at how our parents boogied—we humans learn by mimicking. Just imagine your spouse’s father dancing with your own mother, or some other familial counterpart pairing, and you probably see something resembling your own relationship. Psychology research tells us that our stories and patterns of relating form very early in life, and persist for decades. We carry the lessons, traditions, and burdens of our families of origin in our neurons and even our DNA—we cannot escape them.

Not that we need to or should. Each of us is the product of all the atomic, molecular, cellular, interpersonal, and interstellar interfaces that created and continue to recreate us, in an infinite and complex web of moments and contexts. It’s really quite beautiful, when I stop to think about it. We can hear echoes of our ancestors in our children. We pass on core values and family traditions with tribal pride, maintain bonds that hold us up through adversity, and anchor to relationships of identity and belonging. We can also choose to forge new paths for discovery and growth, diverging from generations of redundant dysfunction and suffering. Through iterative tribal mergers our children inherit all that came before them—the good and the bad—and the universe both differentiates and unifies with each succeeding generation, with every single individual.

Each dandelion seed is a miniature version of the whole flower itself. Each human family is a subset of the family of humanity. We are all uniquely ourselves, and we also belong wholly to one another.

Nothing stays the same for long. And some things never change.

It’s just a thing of beauty, no?

Wide Open Spaces

Posted on March 24, 2019 by Catherine Cheng, MD

What to write on vacation? Depends on the schedule, no? Happily, on my Rocky Mountain escape this week, time lolls wide open. How rare and precious to have these days with no commitments, no agenda, and a true feeling of detachment! Wow. How refreshing, nourishing, relaxing, and challenging. No patients to see, meetings to attend, immediate work crises to solve. I feel at once liberated and anxious—as if I enjoy the bright Colorado sun now, but there must be some black cloud looming over the ridge to the west. *sigh*

The LOH retreat positively saturated me last weekend—mind, body, and soul. I had Hippie Zealot Conference High, for sure. And as so often happens, synthesizing learnings and insights proved challenging off the mountain and in real life, especially with only four intense days of re-entry before leaving again for spring break. But now I have time and space—physical and mental—to process, hallelujah!

It never ceases to amaze me, the cosmic collision of ideas and insights that simultaneously shape my personal and professional development. It’s like I feel the universe’s Michelangelo, Van Gogh, and Einstein hands sculpting and unifying my consciousness at all levels—it’s awesome!!

Weeks prior to LOH, my own coach Christine and my coach friend Donna each independently introduced me to the work of Jennifer Garvey Berger, expert in adult development and leadership coaching. She incorporates ideas of complexity and systems, central tenets of LOH training, in her philosophy. I started listening to her book, Changing on the Job, the week before LOH started. My friends came to Berger’s work separately (they don’t know each other, which I intend to remedy soon), and the temporal overlap of their new learning with my own makes my heart leap—my friendships are, without question, divinely inspired. The central learning for me so far is recognition of my current and aspirational states of development as a person in all aspects of life. I look forward to acquiring and practicing more skills for growth—it is a lifelong process!

Two weeks ago, while searching links for my Thank You post to Ben Zander, I came across Rosamund Stone Zander’s book, Pathways to Possibility, the follow up to their co-authored book, The Art of Possibility, still my favorite book of all time. I started PtP days before LOH; the synergism of ideas almost overwhelmed me. I finished it last week and holy cow, this is advanced practice personal development. The stories we tell, the ones that rule our relationships and lives, can be so deeply entrenched that even when we recognize their dysfunction, revising them feels almost impossible. In my personal life, I recognize intellectually that I hold onto some seriously destructive stories—ones that cause chronic and palpable suffering not just for me but those closest to me. I lose circulation in my figurative hands, my emotional grip on these stories is so tight, and I still refuse to let go of them. It is positively frustrating and fascinating. I know this stubborn intransigence has untoward effects on my leadership capacity and style at work, however indirectly, because I firmly believe that ‘how we do anything is how we do everything.’ It just kills me—like a padlocked steel door in the long hallway of self-awareness, behind which live insight and psychological freedom—I know I have the key somewhere, I just can’t find it yet. I will return repeatedly to integrate the practices in this book, like I do to AoP. And, I get better every year at holding myself with a little more compassion. We’re all here doing our best; I am no exception. Nobody is better supported in this work of self-discovery than I. So I journey on mostly joyfully, surrounded by fellow wayfinders, working on ourselves for the benefit of us all. Onward!

I started this post with at least two other ideas to write about, but I’ll hold off. I have four more days here in the mountains. More time and space to think on, manipulate, and start to apprehend all of these ideas and learnings of late. My thank you cards, washi tape, journal, and laptop are spread out over the coffee table. My favorite movies play on DVD and cable as pleasant and entertaining background ambiance. What a gift and a blessing are time and space. May I savor these days with deep and sustaining gratitude.

This Is My Hogwarts

Posted on March 17, 2019 by Catherine Cheng, MD

My friends, I belong. This weekend marked the beginning of a ten month training program in communication, leadership, connection, and creativity. 9 of us made it to Colorado after the bomb cyclone (Patrick, we missed you—can’t wait to meet you in May!) to launch Cohort 11 of Leading Organizations to Health (LOH). Our teachers, Tony Suchman and Diane Rawlins, led us through three days of introspection, skills acquisition and practice, and formation in community. It all happened at the Sylvan Dale Guest Ranch in Loveland, surrounded by mountains, river, wildlife, and a rich history of family and hospitality.

We are training in relationship-centered care and administration, helping one another embody our best relationship tendencies, so we may help our organizations function at higher levels of connection and effectiveness. It’s too exciting!

I walked into the lodge at Sylvan Dale, saw the vaulted ceiling with the icicle lights, and immediately thought of Hogwarts. I came to this place, called by something to the Why of my soul, to be with others like me. We are here to train, to hone our skills for good. Within the first session I realized I can totally be myself in this crowd. Here, I’m no longer a lone voice focused on relationships ahead of everything else, no longer the only one who cannot help seeing how the nature of our relationships permeates every interaction, every decision—and how we recreate them in every moment. No more self-editing and explaining, tip-toeing around what matters most to me. I can fully inhabit my relationship convictions here, in this space and among these new friends. I feel an ease of purpose and values in this group that I come to, like a deep well, to fill my bucket and irrigate my garden of personal and professional growth. Here, I am not a black sheep.

I now have 9 new people-nodes to connect and integrate into my existing relationship webs—a new and emerging system. We share stories with common themes, new insights, and mutual support. These ten months we will form and evolve as individuals as well as a community. It’s a type of love, really… At least that’s how it feels to me. Hooray!

Thank you, Mr. Zander

Posted on March 10, 2019 by Catherine Cheng, MD

Dear Mr. Zander, I met you almost 10 years ago and you transformed my life.

You and Ms. Zander gave the keynote address at the second ever Harvard conference on coaching in healthcare. I was one of only a handful of physicians in attendance. You discussed the central tenets of your book, The Art of Possibility. I could not wait to get my copy signed, and you also graciously agreed to a photo. I have since read and listened to your book at least a dozen times, and every time I gain something new and relevant. The names of the practices ring in my consciousness on a regular basis: Give the A, Rule #6, Be a Contribution, Lead From Any Chair, and Be the Board. I describe the practices and their benefits, still, to anyone who will listen.

Back in 2015 I boldly contacted the Boston Philharmonic to see if you could speak at the American College of Physicians Illinois Chapter Meeting. You actually spoke to me on the phone and considered coming! I was honored. Though it did not work out (I knew it was the longest of long shots), it amazed me that someone as sought after as you would personally take a phone call from a random, unknown doctor in Chicago. Later that year, when I attended the Harvard Writers conference (the birthplace of this blog), I had the honor of observing a master class where I witnessed you love some young musicians into their best selves. They believed in themselves because you saw them, loved them, and believed in them. That is the best thing any teacher can do for a student.

Throughout these last ten years, I have continued to seek, study, and attempt to apply learnings from authors, teachers, and mentors like you, people who see the world as broken as it is, and also the hope of humanity’s strengths and connections. There is no shortage of people trying to help us all be better, for ourselves and one another, and no more urgent time or need for this teaching than now. I count myself beyond fortunate to have benefited from your influence and inspiration so early in my life and career, to have you as my model. No doubt I am only one of thousands, if not tens (hundreds?) of thousands, whose lives you have transformed for the better. I wish you an ever broader and higher platform from which to reach countless more people and organizations. I wish you peace, health, and joy in all your endeavors and relationships.

Please know how much you have meant to so many.

Sincerely,

Catherine Cheng, MD

Healing Through Connection

The Inner Work of Physician-Patient Relationship…And Other Things