Physician as Trainer

“No way, are you kidding me?” I would have said, if asked to do uphill sprint intervals this time last year. I also would never have ridden a bike through traffic and then up a training hill (or ridden a bike at all, really—biking has always scared me), or tried walk/jog/running from the bottom to the top of Ryan Gulch Road in Silverthorne, Colorado, an 800 foot climb over 2.5 miles.

How is it then, that this summer, I did all of these things? I credit my relationship with my trainer, Melissa. I started seeing her in January, 2014. I had thought for a (long) while that I needed to start exercising again, but after 15 sedentary years and two pregnancies, I barely recognized my body or its capabilities. I thought I could train for a few months and be back in shape, doing all things I used to do.

Little did I know what lay ahead in the actual training. First I had to identify some dysfunctional movement patterns I had developed over the years (wait, what do you mean, ‘fire your glutes,’ I’m supposed to be able to do that?), and correct them before loading them with weights and speed. I had to accept how out of shape I actually was, and reconcile the long, uphill path to physical health. And I am not an unhealthy person! I have no chronic medical problems, sleep well, and take no medications. I experience minor aches and pains that are generally attributable and transient. But last year I was afraid to start an exercise program on my own—I knew I needed help.

The first few sessions were fantastic, full of learning and potential. Turns out you can learn to fire your butt muscles in a one hour session—gluteal amnesia can be cured! But as each meeting revealed yet another pattern to be corrected, I got discouraged. How can there be so many things wrong with me, and when can I work out for real, already? After our first interval training session I wound up on the floor, dizzy, nauseated, and disgusted with myself. Later, Melissa demonstrated 14kg kettle bell swings. She told me I would do them, too—yeah, right (smirk)!  And, over time: Turkish get-ups, first ‘naked’ and then with weights, TRX lifting, Rip Stick swinging, planking, running in Kangoo Jumps, jump roping, kettle bell swinging and snatching, hill training on a bike, and, finally, metabolic circuit training that really gets my heart rate up—without ending up on the floor—I have actually done it all.

Why is the relationship key? From the beginning, Melissa has made it safe for me to show up every week, however I’m feeling and whatever is happening. It’s okay to tell her that something we did last week caused me pain. If I feel apprehensive about something she wants me to try, I can say so. She does not judge me, look down on me, or belittle me for what I cannot (or will not) do. She also does not judge herself. That I have pain is not necessarily her fault. Neither is the fact that I push myself to the point of dizziness and nausea. She holds the space for me to bring my concerns, without blaming or getting defensive. She states her observations objectively, of both my movements and how my personality and attitude affect my training. I have a hard time pacing myself, and she helps me monitor for and manage my tendency toward overexertion.

She gives me permission to just bring what I got. We go from there, wherever it is, and see how far we get. I often surprise myself with what I can do! As a result, my confidence and motivation have dramatically increased. These days when she offers a new activity, I say, “Great, let’s try it out!” It’s okay to fail, if that’s what you want to call it, because I always learn something to apply next time. Through it all, I know she is there to coach and support me, without judgment, and always with love.

It takes time and practice to acquire new skills and habits—‘way more than I initially thought! But now I think differently—hills are challenges rather than enemies. I look forward to what I will be able to do next, including uphill sprint intervals at 9000 feet—maybe next time—this time I did them at 5700 feet.

Melissa helps me stay on course in training with knowledge, application, openness and compassion. I can do the same for my patients and their health. When I withhold judgment about patients’ physical and motivational limitations, I make it safe for them to bring their fears and aspirations to every visit. I can meet them where they are each time, and hold space for the inevitable roadblocks: medication side effects, obstacles to behavior change, complications of treatment. We can then find a way through together, because we both know we’re in it for the long haul. Physicians and trainers may have more in common than we think.

I Am A Lone Nut!

At the end of my recent physician burnout/resilience presentation, I stood wondering if it meant anything to anybody. I did my best to follow Nancy Duarte’s structure in her book, Resonate: Make the audience the hero, contrast what is and what could be in story with texture and emotion, sound the call to action and describe the blissful future! Every time I give this talk I feel energized and passionate by the end, but most of the audience looks positively neutral. Thankfully, a few usually approach me afterward with words of praise and I feel somewhat validated. I remind myself, if only one person is moved, then I have made a difference and it was worth presenting.

When I spoke to editors, writers, and instructors at the Harvard writing conference, they said I should not write for both patients and physicians, I had to pick one. They told me to identify my audience (but keep it broad), and then differentiate myself from all the other authors writing for that audience. It feels like opening a retail shop. What will I sell? Who do I want to shop here? What is my purpose? It’s not to make money; it’s to make a positive impact on the community, to fill a need. Some people will walk in, look around, and walk out without buying anything. That’s okay. If I stay open long enough, they may wonder, ‘What’s so great about her store that she’s still in business? Maybe I should look again.’ They may eventually make a purchase, if they see something of value.

Others will enter, feel immediately at home, and linger in the aisles, soaking up the aesthetics, wishing they had more time to spend. One shiny piece will catch an eye, they’ll snatch it up, and come back as soon as they can, looking for more treasures. They belong here, and so do I. Now I know, I’m not simply writing for patients and physicians; I’m writing for those patients and physicians who, like me, believe that our healthcare system can thrive again only if we all work to reclaim our relationships.

I aim to start a movement.

But one does not accomplish this by barking a generic message to everybody who walks by. Doctors come to noon conference as a routine, a social and academic ritual. We earn one hour of continuing education credit for showing up, staying to the end, and completing the requisite evaluation forms, regardless of how much we actually engage with the presentation content. It occurred to me this time, that there are always a few in the audience primed to receive and respond to my message—they are my tribe. While some parts of my talk may resonate with some people, the whole talk will resonate deeply with those few. They are my target audience. Why? Because they are the ones who will take up the torch, hail the call to action, and participate in the movement now. They feel, like I do, a visceral agitation for this change.

To the attendees who don’t feel it (yet), I must seem like some lone nut, roaming the room and flailing my arms about. They may remember something I say and apply it for a short time, and forget me in a few days. But for my fellow tribe members, my waving and shouting (I don’t really shout) stirs something kindred and profound. They want to wave and shout back, “I get it, I get it! Hallelujah!” They will carry my message with them and share it with anyone who will listen, because it is their message, too. I know because I get this way when I hear someone speak who believes what I believe. It happens at professional meetings; I call it the Hippie-Zealot Conference High.

I get the idea of the ‘lone nut’ from Derek Sivers’ TED talk, “How to Start A Movement.” Sometimes I feel like the one on the amphitheater lawn, dancing unabashedly, provoking expressions of ‘weirdo’ from others. But there will be tribe members there, the townspeople who love my shop. They will get up and dance with me, if only I can connect with them. Maybe all it takes is eye contact, a welcoming smile, or an exuberant gesture to join in. Once they stand up and start dancing, pretty soon the gawkers may feel our collective energy, shuffle cautiously at first, then let loose and get down with abandon. We will all be in relationship for the better.

Derek Sivers calls those tribe members ‘the first followers.’ I prefer to think of them as fellow lone nuts. Lone nut status, especially with a microphone (or megaphone) can feel special, and it also gets lonely. I would much rather live and work among mixed nuts, with complementary and mutually enhancing, yet unique, contributions to the jar.

From now on, when I present on physician resilience, patient-physician relationship, or any other passion, I will make a concerted effort to acknowledge my fellow lone nuts. I will call out to them especially loudly, and invite them personally to join the movement. Then we will all feel empowered to rally the masses, one small circle at a time, until everybody’s up and dancing, happy, strong, and together.

The Soft Stuff Matters

Blogging 101, Assignment #9: Write a post that builds on one of the comments you left yesterday.

It’s from today, but I think it still counts.

If you have not already visited Catching My Drift by Pam Kirst, I highly recommend it. This morning, when I should have been preparing more diligently for my noontime presentation, I found myself drawn into and reflecting on her story, “A Wheel That Never Squeaks.” A college administrator puts together a series of student panels to help faculty address the unique needs of certain groups, such as single moms and students with autism. An advisor asks her to arrange a session for returning veterans, and the story unfolds as she learns from three veteran students about how their military experiences influence their campus lives. One cannot stand the disrespect that a professor tolerates from a fellow student. Another feels a sense of urgency to earn his degree so he may once again serve as breadwinner for his family. The third looks more like a hippie than a soldier, with a long ponytail and body piercings.

Some lines that grabbed me:

“The message was always the same: We want to help our students succeed.  We are not going to dumb it down for anyone, but we do want to work with unique situations.”

“Lesson number one, she thought to herself.  Lose the stereotype of what I think a returning veteran looks like.”

“Did you notice they all sat facing the door?  Returning veterans find it very hard to sit with their backs to a door–it goes against all their training.”

I encourage you to read the whole story, if you haven’t already. For me, it brought multiple aspects of physicians’ work into specific relief.

My comment:  “I’m getting ready to present today on physician burnout and resilience. Continuing education at this hospital occurs every Monday around lunch. Wouldn’t it be great if every month or so, one of those sessions were devoted to some humanist aspect of practice? Who are our patients? What are they dealing with outside of their medical problems? How can we best serve them? And holy cow, what would a panel of patients say to an audience of doctors??”

I have given versions of my burnout/resilience talk three times before today, each time to a different audience. Today was in a community hospital, to about 20 or so primary care physicians and some subspecialists. It was their weekly noon conference, with hot food provided. As the doctors trickled into the basement conference room, we spoke casually about burnout—so much regulation, administrative red tape, stress. Suicide came up–one doctor mentioned that he himself knew three doctors who all took their own lives. When I asked the Continuing Medical Education coordinator how often they have a presentation on non-clinical topics, she said maybe once or twice a year. Does this surprise you?

The breadth and depth of medical knowledge grows exponentially these days. Even in subspecialties, physicians must work harder to keep up with updated guidelines, new technologies, and patient expectations. So it makes sense that ‘continuing education’ would center around the ‘hard’ stuff—clinical knowledge and practice.

But what about the ‘soft’ stuff? Do we assume that all physicians just know how to manage their relationships with patients, staff, and colleagues? With themselves? That they practice optimal strategies for maintaining their own well-being, in this complex and demanding healthcare environment?

At first I thought of practicing physicians as the faculty in the college story, in need of learning how better to connect with their diverse patients. I want to go to grand rounds and hear from a panel of patients with autism about their experience in our healthcare system. I want a case manager to show me the resources available for my patients whose insurance does not cover mental health services. I want to connect with my colleagues in other specialties, learn how I can best prepare my patients to see them in consultation, and know the rationale behind their decisions. I see my own presentation as an attempt to fill this gap, inviting my colleagues to consider ways they can take charge of their own happiness at work.

On further reflection, I see my colleagues also as the returning veteran students. In the story, they are the ‘wheels that never squeak.’ Their training and mindset preclude them from complaining, even while they feel severe discomfort in their classroom surroundings. Similarly, many physicians experience great distress at work but don’t let on. For most of us, effective self-care is never role modeled in our training, let alone explicitly taught. If we express fatigue, sadness, or feeling overwhelmed, we are often shamed as being weak, rather than encouraged and shown how to overcome these challenges. Some of us become the ‘non-squeaking wheel,’ with deadly consequences. The suicide rate for physicians is estimated to be 1.4 to 4 times greater than the general population.

“The message was always the same: We want to help our students succeed.  We are not going to dumb it down for anyone, but we do want to work with unique situations.”  When we sanction conversations and conferences around the soft stuff, we validate its importance. We want our patients to succeed by helping them understand their illnesses and treatments. We want our physicians to succeed by giving them the tools to communicate and connect effectively with patients. This serves everybody; it’s a win-win.

“Lesson number one, she thought to herself.  Lose the stereotype of what I think a returning veteran looks like.”  Let’s lose the stereotype of the bullet-proof physician, the one who helps all others and never needs help herself. Let’s lose the stereotype of the lazy patient, who cares less about his health than his doctor does. Let’s find ways to know each other’s challenges, and see one another as individuals who deserve our full attention and honest caring.

“Did you notice they all sat facing the door?  Returning veterans find it very hard to sit with their backs to a door–it goes against all their training.” What do we need to notice about one another? What details do we miss in our daily routines that, if we knew, could help us connect and heal one another?

Thank you, Pam, for giving me more to ponder. I hope I can contribute to these conversations and make our system function better for both patients and doctors.