Why I Cried On Rounds

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Wow friends, I’m inspired.  You know that’s the case because I sit here less than 24 hours after my last post, writing again.

Today I learned about Public Narrative during the ICCH conference workshop entitled, “How to Become an Effective Advocate for Humanism in Your Healthcare Organization”.  The process was developed by Marshall Ganz, at Harvard.  Here is the course description (MLD-355M Public Narrative: Self, Us, Now):

Questions of what I am called to do, what is my community called to do, and what we are called to do now are at least as old as the three questions posed by the first century Jerusalem sage, Rabbi Hillel:

If I am not for myself, who will be for me?

When I am for myself alone, what am I?

if not now, when?

This course offers students an opportunity to develop their capacity to lead by asking themselves these questions at a time in their lives when it really matters. . . and learning how to ask them of others. Public narrative is the leadership practice of translating values into action. To lead is to accept responsibility for enabling others to achieve shared purpose in the face of uncertainty. Public narrative is a discursive process through which individuals, communities, and nations learn to make choices, construct identity, and inspire action. Responding to challenges with agency requires courage that is grounded in our capacity to access hope over fear; empathy over alienation; and self-worth over self-doubt. We can use public narrative to link our own calling to that of our community to a call to action. It is learning how to tell a story of self, a story of us, and a story of now. Because it engages the “head” and the “heart” narrative can instruct and inspire – teaching us not only why we should act, but moving us to act. Based on a pedagogy of reflective practice, this course offers students the opportunity to work in groups to learn to tell their own public narrative.

See also this video, where Ganz describes the central tenets himself.

In our introductory workshop today, we were invited to try writing our own narrative, and provide/receive feedback from a fellow participant.  My responses to the exercise prompts are below.  Just want to share.

  1. What is the change you want to make in the world:  Your Story of Now?

I wish to improve all of our relationships:  To foster meaningful personal connections in all realms, in an increasingly disconnected (yet deceptively ‘connected’) world.  This includes doctor-patient, doctor-administration, parent-child, teacher-learner, political opponent, colleague, friend, spouse relationships and more.  We all desperately need deep connection now more than ever.

  1. Why are you called to make this change: What specific experiences have shaped your Story of Self?

I am a Boundary Spanner.  From early in life I have repeatedly and consistently found myself in Middle Spaces, serving as liaison between divergent perspectives, such as family members, Chinese and American culture, conventional and alternative medicine, patients and physicians, physicians and our leaders.  I have an easy ability to take perspectives, withhold judgment, and communicate to connect.  I am perfectly positioned to do this work—I live at the intersection of each of these relationships and others, and I am comfortable serving as a bridge.

  1. What personal story can you tell that will help others understand why you want to make that change? What is the challenge?  The choice?  The Outcome?

In my fourth year of medical school, I rotated on nephrology consults.  Hospital care teams called us to evaluate their patients who had new kidney failure in the hospital, to advise on potential causes and make recommendations for treatment.  I had become confident in my knowledge in renal pathophysiology and collegial communication skills.  On this day we were consulted on a patient in the intensive care unit.  I was taken aback when I saw the man—a Vietnamese man close to my dad’s age.  He was gravely ill, intubated, swollen and jaundiced.  I met his daughter, who looked about my age.  Her hair was jet black and straight, cut like a schoolgirl’s.  She wore a modest t-shirt tucked into high-waisted jeans that looked about a decade behind the current fashion trends.  She did not speak English, so our encounter was brief.  But I remember being struck by the utter confusion and fear in her countenance.  She looked like a deer in the headlights.

I conducted the usual chart review, lab analysis, and physical exam.  I thought through the usual causes of acute kidney failure in critically ill patients, and then the concurrent conditions that made treatment a fine balance of volume, pressure, and perfusion (sepsis, heart failure, kidney failure).  But this case, though medically typical, was emotionally fraught for me.  I saw my own family in this patient and his daughter.  What if my dad had fallen critically ill when he arrived in the US back in the 1970s?  Who could have advocated for him, and how could his care team know what they needed in order to care well for him?  My heart went out to this man, likely about do die, and his daughter, apparently alone to manage everything for him and herself.  I related in a way that surprised and scared me, and I felt vaguely uncomfortable.

So when I overheard the ICU and nephrology consult residents making offhand fun of his monosyllabic last name, as so many people had done to my name growing up, I lost it.  I started crying right there in the unit, or maybe when our team rounded, I don’t remember.  I felt embarrassed and also angry.  How unfair.  These residents had not even known what they had done, they had no idea that I reacted to their words and attitude, which I imagine they would have defended as benign.  I was too embarrassed to say why I was so upset—felt it was selfish, unimportant.  I worried they would think I was being hypersensitive, over-reactive.  I also worried, I realize now, that I would hurt their feelings if I told them how much their passing, offhand remarks had hurt me.  It was too much, and I could not voice any of it.

So my team, perplexed and taken by surprise even more than I, just sat.  They were confused, concerned; they did not know what to do, had no skills at their fingertips to make it safe for me to open up and share.  I don’t remember any gestures of support or reassuring touch.  They sat, like deer in headlights.

My choice was to speak up or not.  To bring attention to what might today, I suppose, be labelled a microaggression?  I chose not to speak.  The outcome is that I regret.  I regret that nobody had any way of consoling me, even as they did not know what was happening.  I regret that I did not have the courage or language to describe my experience, that I did not advocate for myself and future Asian immigrant patients.  I liked our attending.  He was a decent and caring man.  But he had no idea what to do.  If he had briefly halted rounds and taken me aside privately, or asked to sit down later, I might have shared my story then.  But he did not.  I pulled myself together, we completed rounds, and nobody ever brought it up again that I remember, myself included.  He wrote a very generous letter of recommendation for me for residency.

My challenge today was to make sense of this sudden and profound emotional hijack, after marveling briefly that this was the only story that emerged to tell.  I had not thought about this incident in many years already.  My pair/share workshop partner pointed out, insightfully, that once again I found myself in the Middle Space, spanning the boundary between the modern American healthcare system and an East Asian immigrant family unit, both personally familiar to me, and mutually unintelligible to the people on either side.  “I’m not surprised that you’re trying to do something with this story,” she said.  Yes.  My calling is to foster awareness, respect, and mutual understanding between all people.

This is why I get Hippie Zealot Conference High, because insights like this hit me every time I commune with my meeting tribes.  Can’t wait to see what happens tomorrow.

Medicine:  Science + Humanity = Professional Pride

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Lots of learning this month, friends.  I’m overwhelmed and overjoyed, and proud of my profession.

It’s too much to write about in one post, but I will try all the same, in order of occurrence.

18 October 2019

Once again I had the privilege of meeting with medical students, this time to discuss their experience of leadership in medicine.  As is my new custom, I started with an appreciative inquiry exercise: What is the best thing about medicine, WHY do you do this?  One of their responses:

“The medical encounter is a unique combination of compassion and intellect—the conversation is my favorite thing, and that I also get to help.”

19 October 2019

Looking through the basement bookshelf, I came across my medical school application from 1994.  The general application included a one page personal statement, in which I wrote:

“Science, and the human body in particular, have always fascinated me… In practice, while I pursue the challenge of each new patient’s illness, I want to share with them my enthusiasm for the science of medicine…  But being a doctor involves more than curing people’s illnesses…  It is the job of the physician to reassure and comfort the patient…  In my practice I will…do my best to communicate with (patients) in terms they will accept.  The best way to comfort people is to relate to them.  I believe this skill will make me understand not only patients’ medical needs, but their emotional and psychological needs as well…  I hope to keep learning from my patients in the future.”

Turns out I’ve been both a science nerd, and also thinking and writing about relationships and connection for a while now, go figure.

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25-26 October 2019

This year’s ACP Illinois Chapter Meeting was the best one in recent years, in my humble opinion.  I’m so proud that under the leadership of our Northern Region Governer, Dr. Suja Mathew, we were able to present a robust clinical education conference, as is the ACP tradition.  Along with sessions on diabetes, heart failure, office orthopaedics, and cancer survivorship, however, we also included sessions on critical social and public health issues, such as diversity/inclusion, the impact of social media, firearm injury and death, medical marijuana, trauma-informed care, and sexual harassment in the workplace.  Esteemed colleagues from across the country came to share their expertise.  Here are just a few examples of Science + Humanity, in action every day in our work:

Diabetes

Science:  We now understand that it’s the wide swings in blood sugar, and especially very low sugar, that lead to end organ damage.  We have new classes of drugs with novel mechanisms of action.  They decrease the burden of glucose control on pancreas cells, and also seem to prevent heart failure in some patients.  Humanity:  All diabetic patients need education—face to face time with a trained professional who can teach them about the disease and how to manage it. Even the most highly educated and most well-informed person cannot automatically know how to be a diabetes patient without the help of these medical team members.  More and more, diabetes care in particular is a team sport, and our collective skills get better every year.

Cancer

Science: We are curing cancer.  There are more survivors now than ever before, thanks to targeted genetic and immunotherapy and minimally invasive surgery, among other treatments.  Humanity:  Survivorship starts at the time of diagnosis, and cancer patients have both unique and diverse needs and concerns.  Complications from treatment such as neuropathy and heart failure can occur years out from treatment, and the psychosocial consequences for patients and their families can be lasting and transformative.  The better we understand this as their care teams, the healthier and happier our patients will be.

Childhood Trauma

Science: Since the 1970s, cumulative evidence shows that Adverse Childhood Experiences and trauma correlate with an increased risk of negative health behaviors, mental illness, chronic diseases such as diabetes and heart disease, decreased academic performance, limited professional productivity, and early death.  And they appear to affect each of these outcomes independently.  In the Tree of ACEs, branches and leaves represent the interpersonal experiences.  We are only starting to understand the roles played by Adverse Collective Historical Events (slavery, genocide, mass incarceration, forced displacements)—the soil, and Adverse Community Environments (poverty, violence)—the roots.  HumanityThe key factor that correlates with escape from the early mortality path from ACEs is a stable and nurturing relationship with an adult caregiver.  As healthcare providers, we have a unique and important part to play in the healing of all ACEs—our patients’ and our own—and all evidence points to the quality of our patient-provider relationships as foundation—no surprise.

Gun Violence

Science: In 2012 33,000 people died from firearm injuries (it was up to 40,000 in 2018); 62% of these deaths were suicides.  That same year there were 62,000 nonfatal firearm injuries, 72% of which were assault, 5% self-inflicted, and 17% unintentional.  Higher rates of gun ownership correlate with higher rates of death from firearm injuries.  States with both background checks and waiting periods have lower rates of suicide by firearm compared to those with background checks only.  It is still unclear whether states with more lax concealed carry laws have different rates of firearm related deaths compared to stricter states.  Humanity: Though mass shootings dominate the media, the majority of deaths from firearms are self-inflicted.  The acute impulsivity of mental illness, combined with an accessible, loaded firearm, destroys lives—whole families and communities at a time.  Our job as physician advocates is to not alienate gun owners, and rather enroll and recruit their help to address the factors that take our friends and loved ones from us.  It’s not an Us vs. Them fight over rights.  It’s a shared challenge to create policy that honors our unique national history and culture, and also effectively addresses our public health crises.  Here is where our highest notions of collaboration, respect, and shared purpose must be exercised.

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27-30 October 2019

Today I arrived in San Diego for the International Conference on Communication in Healthcare, my first time at this meeting.  Many of the sessions will present research on effective ways to teach communication skills to trainees, factors that impact health literacy, and methods for measuring effective communication.  This conference is all about the science of communication in healthcare.  And it’s also about the humanity.  The first plenary speaker was Dr. Lisa Fitzpatrick, who interviews people on the streets of DC in her series, “Dr. Lisa on the Street.”  The videos show over an over how people feel ignored and dismissed by our healthcare system, and how unsafe it is for them to admit what they don’t know or ask questions.  This is one of the only meetings I have attended at which patients are invited to present and voice their perspective.  At the end of this session one patient attendee stood up and spoke words that will guide me throughout this week and my career:  “Doctors may have all the education in the world, and if you cannot talk to your patients in a way that makes them trust you, it really doesn’t matter.”

Sessions I plan to attend:

Moving Health Care from a Team of Experts to an Expert Team

How to Become an Effective Advocate for Humanism in Your Healthcare Organization

Collaboration and Communication Across Multidisciplinary Healthcare Teams

Civility Ninjas:  A Field Guide to Improving Colleague-Colleague Interactions

Understanding and Addressing Mistrust

Shared Decision-Making as Ethical Practice

Thanks for reading to the end, friends.  I know it was a lot.  As I age I learn to hold patience as well as eagerness, absorbing the input as well as creating my own, integrated outputs for good.  How lucky I am to have so many amazing people to keep me company on the journey!

Four days to NaBloPoMo, my fifth attempt, HOLY COW!  Better get to bed…

Better Angels:  Why I Have Committed

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Friends, what is your WHY?  Mine is to cultivate the best relationships between all people, (here comes my spiel [I prefer to call it a mantra—winking emoji]), “because our relationships kill us or save us, and relationships themselves live and die by communication.”

How are you affected by the current political climate?  Are you separated from friends?  Do you feel restricted in your conversations?  Do you self-edit more than before?  Or are you emboldened to speak your mind, finally freed from the social muzzles of more repressed times?  How have politics in the 21st Century affected your relationships?

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I first learned of Better Angels when I read David Blankenhorn’s article, “The 7 Habits of Highly Depolarizing People,” written before the 2016 election.  I was intrigued by the organization but could not figure out how to get involved.  Last year I asked my Facebook friends which charity they thought I should fundraise for—I support so many causes in theory, but could not decide where to focus my efforts.  One insightful friend suggested Better Angels.  I did not end up fundraising for anyone, but I started following Angels on Facebook and signed up for the newsletters.  This May I participated in a skills workshop and wrote about it.  The objective in these workshops is for attendees to learn and practice listening and speaking skills, to facilitate mutual understanding and connection between liberals (Blues) and conservatives (Reds).  The workshops are brilliantly structured to make engagement safe and productive.  I decided I wanted to be part of this solution.

In August I attended my second workshop, “Depolarizing from Within,” aimed at helping us help our own ‘side’ combat the 4 Horsemen of Polarization that we unleash on the other side:  Stereoptyping, Dismissing, Ridiculing, and Contempt.  I took notes on the moderator’s methods this time, as I had committed to training to become a moderator.  Like in teaching, he had to set clear expectations and ground rules.  He had to control the session and politely but firmly interrupt people’s monologues and keep us on task.  This was harder than I expected—many of us wanted to depolarize from the other side rather than our own—self-scrutiny and –regulation is hard.  Going against group think and calling out our peers feels scary and vulnerable.  But we can do it if we have the skills and motivation.  It is essential if we want to reconnect with our loved ones ‘on the other side.’

I read the moderator training materials and watched the videos over the summer.  When I found myself feeling triggered watching a Red/Blue workshop online, I wondered if I’m really up for facilitating such an event.  Moderators, after all, must exude sincere neutrality and make all attendees feel welcome.  We are the leaders in the room; we set the tone.  For the sake of the work, we cannot afford to get emotionally agitated by anything any attendee says.  That means not only in our words, but our body language, facial expressions—people must feel us being professional at all times.  So to test myself, I registered for the next Red/Blue workshop in my area as a participant.

The event was almost cancelled because not enough Reds had registered.  Chicago and Evanston are very Blue cities, and I’m learning how ostracized and unwelcome my Red peers feel among us progressives.  So I’m so grateful for Red folks who came at our organizer’s behest—her friends who did it as a favor to her.  More than once during the morning, we heard how apprehensive some of them felt, not knowing what to expect, and not used to feeling free to express their views.  This makes me so sad, and I feel strongly that we Blues have to own our part in it.  Regardless of how badly we feel our conservative counterparts anywhere behave, it does not excuse our own ad hominem.

About a week before the workshop, we found out Van Jones and his crew would come to film the whole thing and then interview some of us afterward.  With very mixed feelings, I agreed to wear a microphone and appear on camera.  He told us at the beginning that of the 4 hour event, 4 minutes would be aired.  So we could relax.

Not only was I relaxed; I felt positively uplifted and encouraged.  Throughout another set of wisely structured exercises, Red and Blues explored not only our strengths, but our flaws—both ideological and behavioral.  The stage was set for safe self-reflection, and the vulnerability required to practice it.  How often in your conversations, even with people you love, do you feel safe to acknowledge the weaknesses of your ‘side’ and where your group could act better, without someone pouncing on you?  Has it been so long that it doesn’t even occur to you to consider it?  At the end I exchanged contact information with two Reds and another Blue, and I really hope we can continue the conversation.  I will invite them to the skills workshop I will co-moderate next month, my first attempt.

The Better Angels segment aired on the Van Jones Show last night.  It’s about 9 minutes.  I thought the show did an excellent job of highlighting the objective of the organization, and showing perspectives from both sides, as well as an observer, whose notes are worth pausing on and reading, at about 7 minutes.  Please take a look and share your reactions (civilly) in the comments.

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In preparation for Thanksgiving, Better Angels is holding skills workshops across the country in the next weeks.  Find one near you and bring a friend or loved one!  And check out the blog and podcast to read and hear civil, respectful, even friendly Red and Blue perspectives and discourse on issues like gun control and education.

We have so much work to do, my friends.  It feels exhausting and discouraging at times, but not during Better Angels events.  Here the goals and vibe are openness, curiosity, learning, understanding, and above all, connection.  It’s the perfect place for me and my WHY.  So I’m going to stay a while.  I’ got something to contribute here.

 

Help On the Path to Better

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Okay, let’s talk about your eating!

What about your eating habits is already good, that you want to maintain, that you’re proud of?

And where is there room for improvement?

Sometime in the last five years, I started querying my patients about nutrition this way.  It seems to put people more at ease talking about their eating habits, for some reason.  Culturally, we are so judgmental and defensive about food and eating, weight and appearance.  So one day, I decided to start with the positive, and it makes the conversation easier for everybody.  Fascinating!

I did not realize until the past week that this is my personal version of appreciative inquiry (AI).  I have started including AI in my presentations this fall, which is very well received so far.  I got feedback from the talk I gave to my design friends two weeks ago.  They liked focusing on the positives of work before problem solving.  This week I presented to a mixed audience of physicians, from all specialties, early career to retired, on burnout.  I chose to make it similarly workshop-like, a very ambitious undertaking in 45 minutes, but we did it!  In the last segment I invited audience members to identify the first step they might take to address their own sources of burnout, or improve their self-care.

One generous physician shared her plan, initially stated as, “Just commit to doing it,” talking about exercise.  After a few more questions, we arrived at her actual plan: figure out what she will do (treadmill); decide how long she can carve out (30 min); find time on the calendar; write it on the calendar; know how she will be held accountable.  Turns out she had already succeeded at executing–5 times a week for 20 weeks this year—STRONG WORK, MAMA!  I wonder if there are other arenas where she applies this same, stepwise approach to making something better in her life, or the lives of her patients.

When I ask patients what needs to happen to improve their health, we inevitably start at the abstract (“Just Do It”) and must work to get to the concrete, granular action steps that will actually result in successful behavior change.  It’s gratifying for both of us to arrive at a plan that the patient him/herself has an active hand in creating.  Then s/he feels ultimate ownership and agency to execute.

These days I also always ask about help.  Who else can keep you on track?  Can your spouse eat healthier with you?  Can your assistant eliminate junk food from lunch meetings?  Can your kids be your food police?  My best friend in college agreed to do this for me our junior year, and I lost all of my freshman fifteen, God bless him (and yes, we are still friends).  When we go shopping and I look tempted to buy yet more of something I already have piles of, my daughter asks, “Do you want me to be your conscience?”  Usually I reply with a hedonist, “No,” but I’m always grateful for the offer, and it does make me think twice.

Often patients return the next year living healthier in one way or another.  Sometimes the plan works; many times they find another way.  Sometimes plans are executed and then derailed.  So we get to work on a new plan, asking all the same questions over again.  It doesn’t have to be a slog!  It’s just what we’ gotta do—keep getting help on the path to better.   It’s my privilege to serve as helper.

These last two weeks (months?), I’m definitely not sleeping enough.  Exercise is hit or miss.  Eating is pretty erratic and unhealthy.  Stress ebbs and flows with travel and events.  But my relationships are thriving and I’m doing some seriously fun and amazing sh*t.  Next year maybe the eating and workouts will be on autopilot and I’ll have to lean on folks to get through rough times.  The path to better always gets blocked, takes detours, and makes us reroute.  Those twists and turns are so much more fun, and we notice so much more beauty that we might otherwise miss, when we take them with good friends, no?  I’m so grateful to have such loving help on the journey, and also honored to offer it.  Onward.

 

The Mark You Make

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Friends, Ozan has written another book!  I know it may seem like it, but he’s not paying me to promote his work, really!  He has offered perks for Inner Circle members, however, like an advance digital copy for preordering, and signed copies when the book is released next April.  In considering what I would ask him to inscribe to my friends in the books I will give them, I realized yet another evocative dimension of my relationships.

If you were to describe your friendships to a third party, or make a meaningful introduction in service of connecting two amazing people, what would you say?  I call it ‘connecting fellow Awesomes,’ and it’s always a pleasure and privilege to serve in this capacity.  I thought to ask Ozan to write to one friend something like, “Cathy thinks the world of you—happy to make such a positive new connection!”  Then I thought, this friend has really made a mark on me.  Then I thought of the mark Ozan has also made, in just 9 months of virtual contact.  And then my mind was blown with the realization of my cosmically marked-up self—the finger, hand, and footprints of all those whom I have contacted.

Years ago I attended the orthopaedic surgery resident graduation dinner with my husband, a happy and fun annual event.  At the end, mingling with faculty and trainees, one of the graduates looked at me and his eyes widened.  “You’re Dr. Cheng!  You were my teaching attending during my third year medicine rotation [7 years prior] at [the hospital where I used to work]!”  I was gratified that his expression was cheerful, rather than distressed or awkward, surprise.  He went on to tell me that I held the team to a high standard of discussion, and that he appreciated my presence and teaching.  I will always remember this encounter with pride and appreciation.

In the past year three patients from my past have resurfaced and told me the positive difference I made it their lives.  I remembered two of them so clearly, both their faces and their names (after 20 years and thousands of patients, I can usually only remember one or other).  Talking to each of them reminded me of all that we had been through together, and I was glad that I had done my job well.

But what about those for whom I have not been a great doctor?  I have had my fair share of patients who left me, for various reasons.  I know I have been seriously disappointing for many.  I wonder how many times I have contributed to patients’ negative overall experience of medicine, and further widened the divide between doctors and patients in our fraught and flawed healthcare system?  Sometimes I look back on my early years of practice and cringe a little—all the writing I do now on empathy, compassion, curiosity, openness, and humility results from years of lessons learned in real time, on real people.  I’m definitely much more adept at it all now than in the beginning.  And I’m still learning—I still get triggered, still fall into old, counterproductive thought and behavior patterns.  Sometimes it feels like I will never be good enough, or enough in general.

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I also think about the people whose marks on me were/are hurtful, dismissive, and otherwise wounding.  It reminds me of carvings I see in the trunks of the beautiful aspens I walked among this weekend.  Did the folks who made them set out to harm the trees?  If they thought the tree might die from their knife marks, would they think twice?  Maybe they were overcome with their profound experience in nature and just wanted to mark it in some way, especially if they shared it with someone they loved (so may initials with plus signs and hearts)?  Sometimes we just want or need to be right, competent, respected, and acknowledged.  So we mark our encounters with stubbornness, aggression, or even violence (in its many forms, overt and cloaked).  Like the strong and flexible aspens, I bear scars from such encounters and still continue to thrive.  Such marks have taught me how to care for myself, and also how not to be toward others.

In the end, how do I reconcile these relationship phenomena?  Sometimes we can see and know the mark we make on others.  Many times we cannot.  Nobody is perfect.  My whole life I will scrape and nick those around me, hopefully never with malicious intent.  I can only hope for their generosity and grace, and forgiveness.

Sister Brené Brown, once again, helps me continue.  In her book Rising Strong, she describes a choice, a mental attitude, that can help us all suffer less.  If you have not read or heard the book, I highly recommend it—it’s my favorite of the 5 of her books I have read.  Assume, she says (with the help of her pediatrician husband), that we are all doing the best we can.  That’s it.  We are all imperfect.  Our circumstances mess with us, our patterns mess with each other, and sometimes it can feel like a strange and inexplicable miracle that we have not all killed one another already.  But choosing to give each other this one, simple, and at times colossally difficult benefit of the doubt, could be what saves us all.

We simply cannot extricate ourselves from each other.  So we can just do your best to take care of one another.  And be prepared to apologize, early and often.

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