Practicing My ABCs

I lifted the boulder that was my head, looking once again at my clinic schedule.  Suddenly the day ahead loomed heavy, dark, oppressive.  No, not really, but I did feel abruptly bummed, when I had arrived that morning in a cheery mood.   My medical assistant noticed the change in my affect and inquired; I pointed to a name on my screen.  The same curtain of dread fell over her being.  “Oh no, I know him.  He’s a jerk!”  We had both made this diagnosis with conviction months before.

This day, I entered the exam room prepared to meet The Jerk.  I took a deep breath and noted my negativity.  I made myself ask extra questions to make sure I wouldn’t miss something, despite the urge to exit the room as soon as possible.  I reviewed medications, discussed his next colonoscopy, all in a perfectly professional manner.  The visit went without incident, nothing to write home about.  Was my care of him medically standard and objectively sound?  Absolutely.  Was I my best self?  Absolutely not.  The difference?  My best self is healing, and he got none of it.  I left Best Me at the door, along with my ability to connect to him as a person.  The other difference?  I suffered through that visit.  Physicians’ work fulfillment comes in large part through meaningful relationships with patients, and I got none of it—it was a lose-lose.

My son’s fourth grade teachers developed a resilience curriculum a few years ago.  The ABCs lesson resonated with me in particular.  (See the links below for more information on the concept.)

A stands for Adversity: The bad thing that happens to us.  In this case it was my patient’s previous behavior, which made my staff and me feel used and ignored.

B stands for Belief: The one(s) we make up based on adverse events.  For example, he is a jerk, a whole jerk, and nothing but a jerk.

C stands for Consequence.  Here’s the rub: The belief, not the adverse event, determines the consequence.  My diagnosis of Jerk hijacked my entire experience of him, precluding the human connection that could have benefited us both.

This story almost repeated itself months later, after a particularly contentious interaction with another patient.  I ranted colorfully to my colleague, who wisely reminded me that the patient might not be a jerk, that I could withhold that judgment yet.  When the patient came next, I took another deep breath.  Maybe she wasn’t a jerk, I repeated internally.  Prepared to meet her best self, I brought mine.  I could literally feel the difference—the tension in my neck loosened; my smile arose more naturally.  Our conversation hit some speed bumps, but we connected, somewhat—there was still something off about her behavior.  As I discussed her case with other specialists who met her, we all agreed that she probably lived somewhere on the autism spectrum.  Now in her late 50s, she had achieved remarkable success in her career, likely with little to no acknowledgement of, or accommodation for, her social challenges.  We genuinely admired her, when at the outset we could have dismissed her as just another Jerk.  In the end the whole team felt satisfied that we had brought our best to meet her needs, and we all learned along the way—a win-win.  By changing my beliefs after a typical adverse event, I steered the consequence of my own experience to a positive, productive place.

Life will never cease to hand us opportunities to practice our ABCs, and as with any skill, we will improve with each occasion.

Below are links to pages that describe the ABCs concept and it’s origins. I have no financial or other interests in these entities.

What Are You Looking For?

One bright, spring Saturday morning in clinic, I met a pleasant middle-aged woman with a cold.  She was new to me, but I recognized her right away—educated professional, mother of two, loving wife, keeper of all schedules and task lists—the command center of her complex world.  Her symptoms had followed the typical arc of a viral upper respiratory infection—fatigue, sore throat, nasal congestion, headache, fever, cough—and it was the green snot that brought her in on day 5.  My physical exam revealed no signs of strep throat or pneumonia…

The relaxed calm I had felt heretofore began to unravel as I contemplated telling this woman, suffering at the peak of acute illness, that I would not prescribe an antibiotic.  In an instant I heard familiar scripts in my head:  She did not have time to be sick; she needed something to kill this infection right away.  She was about to travel and did not want to feel this badly on the plane.  Her regular doctor always gave her an antibiotic for this before.  The snot is green, that means it’s bacterial (it doesn’t)!  My mind’s eye saw hers widen with disappointment, then anger, her posture turn aggressive.  My inner conflict escalated quickly:  Sacrifice the rapport I had just established in the name of antibiotic stewardship, or give in to the misguided pleas of a wrung out fellow working mom, and contribute personally to the scourge of antibiotic overuse and resistance?

Maybe it was the sunny weather that day, or the initial connection I had felt when we talked.  Amid the flurry of mounting anxiety, I had a flash of clarity:  What if I just asked her what she needed?

“What are you looking for from me today?” I queried.

“I just want to make sure I don’t need antibiotics.”

Imagine the absolute and complete relief of realizing that my swelling dread was, in fact, unfounded and unnecessary.  She needed reassurance, and probably formal permission to leave the air traffic control tower and go take a nap.  I cheerily listed all of my self-care recommendations, including a firm admonishment that she take care of herself ahead of all others for at least the next 24 hours, doctor’s orders!  The visit ended happily for us both.

“What are you looking for?”  Such a simple question, and key to understanding one another, as well as ourselves.  I was looking for connection, authority, relationship, and affirmation.  I wanted her to like me, and to trust that I knew my stuff.  And more than once before, I had given my best advice in this situation, only to be rejected as a power-tripping antibiotic extremist.  I had one eye out for an ambush.

What if we ask ourselves more often, both as patients and physicians, “What am I looking for?”  Could we identify biases and fears more readily, and then challenge them?  Would it make asking for and getting what we need a little easier?  What do you think?

The Premise

Do you love your doctor?

Does your doctor love her work?

What would that look like?

How would it transform her care of you and your relationship with her?

When we entered medical school, it felt almost euphoric—we dreamed and worked for years, then the awesome tribe of healers and scientists accepted us into its ranks, woohoooo!  Then we trained and entered practice, and the luster wore off quickly for many of us.  By the end of their third year, 13% of medical students report thinking of suicide at one time or another.  Over half of primary care physicians experience symptoms of burnout.  The suicide rate among physicians dwarfs that of the general population.

Our healthcare system consistently divides physicians from patients, and we all suffer.  Imagine coming to work every morning, knowing your job is to help people in their most vulnerable and intimate states, when you yourself feel utterly exhausted and spent.  We know we let our patients down when we can’t bring our best selves, and it kills us.  Maybe you come to the doctor, hoping for and expecting answers and relief for your suffering, or at least a little compassion, and you find him distant and distracted, even indifferent and cold.  How could you possibly trust him and open up again?  Physicians and patients both take out our frustrations on each other, often without even knowing, and our relationships deteriorate quickly.

I know not all patient-physician relationships feel like this.  But enough do that our healthcare system corrodes at its core.  How often do you meet a doctor who so obviously loves his work that his passion for health rubs off on you, making you want to take better care of yourself?  Think of your most fulfilling relationships—what are the common features?  Likely you respect these people, know them well, forgive them their mistakes, and want the best for them.  They probably feel the same for you.  Both parties feel seen, heard, understood, and accepted.  It’s safe, and you connect.  What if your relationship with your doctor felt like this?

My premise: Patients and physicians have control over one thing above all else: our relationship with each other.  Relationships live and die by communication.  Barriers on the obstacle course of patient-physician communication loom large and formidable. Our system fails us over and again. And it falls to each of us, not the system, to find our way to connection and healing relationships.

In this blog, I explore practices: self-awareness, self-management, empathy, and communication, among others.  I share stories from practice, friendship, marriage, parenting–life!  Because all relationships impact us and teach us.  Our relationships save us.  And through these practices, with some laughs and Aha! moments along the way, we can save the physician-patient relationship.