Author Archives: Catherine Cheng, MD

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About Catherine Cheng, MD

I am a general internist in Chicago, Illinois, mother of two, almost native Coloradan, and Northwestern alum. I want to leave the world better for my having lived, by cultivating the best possible relationships between all who know me, and all whom I influence. Join me on this crazy, idealistic, fascinating journey! Look for new posts on the 10th, 20th, and 30th of each month. Opinions posted here are entirely my own, and in no way reflect the opinions or policies of my employer.

Self-Care:  Act Local, Think Global

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Gotta be quick tonight, friends, as I have sat in front of this screen too long already today!

Creating and putting together slides for three upcoming distinct and related presentations, I am happy to report continued synthesis in my position on the relationships between personal resilience, culture of wellness, and efficiency of practice in medicine.

Drivers of burnout are systemic, no question, and not related to individual physicians’ lack of resilience and strength.  And yet, it will be up to us physicians, more than any other group, to lead change and make the system better for all of us, physicians and patients alike.  But we will not do it ourselves.  We must engage so many other stakeholders—hospital administrators, nurses and other care providers, insurance and pharmaceutical companies (by way of their leaders), and, of course, patients.

How can we engage any of these groups of people effectively?  Do we expect productive conversations and collaborative decision making when we stomp on the offensive with righteous indignation and passive-aggressive name calling?  Even if our language is polished, people can feel our underlying attitude and can tell when we’re not fully authentic.

I still think it starts with self-care.  Because if I’m not well, I cannot show up my best for anyone else.

Be The Change You Seek:

Curious–Kind–Forgiving–Accountable–Humble–Empathic.

How can I be all of these things, which I referenced last week, if I am sleep-deprived, wired on caffeine, skipping meals, and not connected to my emotional support network?  I finally made my own visual for the reciprocal nature of our habits:

Reciprocal Domains of Health Star

If I am attuned and attentive, then the bottom four serve to hold up my relationships, which is how I interface and interact with the universe.  I am one node in multiple subsystems, all connected, overlapping and integrated in larger and layered super-systems.  So the best thing I can do for the universe—to keep the systems intact and optimal—is make myself the strongest, most stable, most reliable node I can be.  I recently attended a strategy meeting where I learned the SWOT framework: for any given project and the people trying to implement it, what are the Strengths, Weaknesses, Opportunities, and Threats?  It occurred to me to apply this framework to my habits:

Health Habits SWOT grid

It really does show how each domain relates to and influences each other one, and makes it all pretty concrete, especially how stress threatens almost everything.

So in the interests of self-care, and in order to care my best for everyone and everything around me, I will now do today’s free 7 minute workout and get to bed.

Onward!

Attune and Attend, Conclusion

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Two posts ago, I related my friend’s experience of feeling unseen and dismissed during a visit to establish care with her new primary care doctor.  I blamed the doctor for not listening, for not exercising his relationship power with enough responsibility.  Last week I described how I see medicine as a complex system, in which each of us is both a contributory and affected member.  I alluded in both posts to forthcoming ‘solutions. ‘

If you have read the last two posts, what were you expecting here, in the last installment?  Quite honestly, the closer I came to writing, the more nervous I got, as if I had promised to deliver some groundbreaking algorithm for instantly fixing physician-patient relationships and our healthcare system at large.  Um, no, sorry.  Hopefully what I write will still be useful.

Events these past weeks have really highlighted for me the profound importance and vulnerability of relationships in a system.  At my kids’ school, a veteran and beloved teacher was terminated suddenly.  No students, staff, faculty or parents were given any warning.  Communication was sparse and poor, and few if any in the community saw evidence of a plan for instruction and emotional support of students in the aftermath.  Students, faculty, and parents alike have raised questions and concerns, all, in my opinion, met with evasion and deflection.  Worst of all, the administration repeatedly refused to acknowledge or own the profoundly negative impact of their actions on their relationships with the school community—a community which they proudly claim to steward.

Once trust has been violated and relationships damaged, the road to recovery looms long and ardent.  Apologies—sincere and heartfelt—serve a necessary and vital role in repair, but they are only the beginning.  We all make mistakes.  But too few of us own up to them and take full responsibility, especially when we have hurt others.  In a medical or educational community, I think we focus too much on scientific and objective decision making, and too little on relationships.  That is to say, we manage the former very intentionally and critically, and the latter only in passing.  This is how, for instance, a surgeon ends up saying to patients, “I can’t help you,” when surgery is not a viable treatment option.  We can always help.

In recent months I have listened to and read myriad resources that point me to some simple (and not easy) guideposts for relationship cultivation and repair.  I have listed the guideposts and their references below.  None of them will surprise you.  You may even roll your eyes and think them cliché.  And yet, all of us in all of our overlapping systems and tribes could do a little better at these practices—physicians and patients, teachers and students, leaders and those they lead.  Which one will you attune and attend to now?  What else should be on the list?

 

Curiosity

By its nature, curiosity makes us open and willing to see more, learn more, and understand more.  What if we got more curious about other people’s feelings and their origins?  What if we did that for ourselves?  Why, for instance, do I get angry when I perceive someone trying to tell me what to do without asking first what I’m thinking?  Could they be motivated by something other than a desire to control and oppress me?  How else could I respond if I thought they were trying to help me solve a problem, if I interpreted their actions as caring rather than interfering?  Check out the distinctions between diversive, epistemic, and empathic curiosity described by Ian Leslie below.  Then the next time you feel conflict coming on, consider these questions (asked in a truly curious tone):

What is this about?

Huh, what else?

Curious, by Ian Leslie

The Art of Possibility by RS and B Zander

Rising Strong and Dare to Lead by Brené Brown.

Kindness

Smiling at a stranger, extending a hand to shake, holding a door, saying hello—small acts of kindness go such a long way.  They benefit not only the recipient and the actor, but also bystanders and witnesses.  Kindness is a primary currency of connection, and reserves can be infinite.  We should never underestimate the potential tidal waves of global benefit from our dropping a pebble of kindness in the waters of humanity.  When a stranger holds the door or my patient asks about my kids, in that moment I feel seen.  I connect with you, my kind counterpart.  My heart lifts ever so slightly, and I am grateful.

A Year of Living Kindly, blog and book by Donna Cameron

Forgiveness

Forgiveness can feel infinitely harder than small acts of kindness.  Will my friend forgive her doctor?  Will I forgive my kids’ school administrators?  What good does it do to carry around grudges, does that get us what we want?  Where else can we direct the energy we expend holding so tightly to resentment?  Could we use it instead to ask, honestly, “What is this about?” or to utter a kind, compassionate word?  Can we see people as people, flawed and trying their best, rather than objects, obstructions, annoyances, and unworthy?

TED Radio Hour, Forgiveness

Leadership and Self-Deception and The Anatomy of Peace by The Arbinger Institute

Accountability

When I hit and dent a parked car, I should leave a note owning my mistake and offering to make up for it—even if I slid on ice, or my child was crying in the back seat, or the other person’s car was parked poorly.  If someone damages my car, I expect the same.  The more we can all/each take responsibility for our own part in any conflict or situation, no more and no less, the better off we will all be.  The key here, when we show up to others, is to do it without qualification.  It’s not, “Yes, I hit your car, but…”  It’s, “I hit your car.  I’m sorry.  How can I make it right?”  I may think you were also in the wrong, but pointing that out in the middle of an argument will not help you own your part, which I need you to do for us to connect and heal.  You may never own your part, and I have no control over that.   But perhaps my example will influence you or others over time.  Humans tend to reciprocate, and mutual exchange of accountability can heal many relationship wounds.

“7 Truths About Accountability That You Need to Know”, Inc.com

Humility

Nobody knows everything, even experts.  And certainly when meeting another human, we cannot possibly know all that has shaped their beliefs, values, and emotions, both in the past and in the moment.  In medicine we have never known more than we do today, and it seems to me that for every new piece of knowledge we acquire, we also discover a hundred new things we didn’t know we didn’t know.  So what gives me the right to assume I have all the answers—that I have nothing to gain or learn by asking curiosity questions?  Why should I feel the need to appear all-knowing?  The opposite of humility is arrogance, and we all know how hard it is to be around people like this.  Turns out students and leaders alike, who practice humility, succeed more than their less humble peers.  Makes sense—humility connects us to others, while arrogance separates.  It’s vulnerable, though, and that can be uncomfortable.  But if we have already cultivated our relationships with curiosity, kindness, forgiveness and accountability, perhaps humility can come a bit more easily.

“The Benefits of Admitting When You Don’t Know” by Tenelle Porter

Empathy

In the end, I believe empathy will save us.  It is the bedrock on which the other skills are built.  Google dictionary defines empathy as “the ability to understand and share the feelings of another.”  It will save us because this is how we truly connect to one another.  But it’s not enough to just have the ability to understand and share others’ feelings.  In order for empathy to connect us, we also need to effectively express that understanding and share the emotions actively.  Active empathy allows us to take another person’s perspective.  It keeps us out of judgment and blame.  It helps us recognize others’ emotions by recognizing our own familiar experiences—empathy is how we relate.  It is the medium of relationship.  Some people possess the gift intuitively.  And it can be learned!  Medical training programs across the country have taught doctors how to be more empathic.  Patients of more empathic physicians do better.  And, physicians themselves do better, too–we feel less burned out and more fulfilled in our work.  We all do better when we connect.

Watch a cartoon and hear Brené Brown explain the importance and benefits of empathy.

“How to Teach Doctors Empathy” by Sandra Boodman

The Empathy Effect by Helen Reiss, MD

 

Please forgive the length this time, friends.

What did you think?  In your next encounter with your doctor or your boss, what do you anticipate?  What do you fear?  How does it feel?  What is that about?  Which of these skills could help?  How will you acquire/hone it?  What help do you need?  What will be better if you achieve it?

What else should be on the list?

Attune and Attend, Continued

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Last week I started and ended my post incensed on behalf of my friend, who felt coldly and arrogantly dismissed by her new doctor.  While I considered that his behavior may be influenced by his circumstances and did not attack his character or make generalizations based on gender, age, etc., I did blame him individually for how my friend felt in his presence.

Another friend read the post and said the doctor was not to blame, rather it’s the system.  We exchanged thoughts and agreed that it was not all the doctor’s fault, and the whole healthcare system in our country is just a big mess in general.  I continue to have daily conversations around physician well-being and systems transformation in medicine, and every single encounter advances my understanding of and awe at the whole situation.  Here are my most current thoughts—bear with me, please.

3 Reciprocal Domains of Professional Fulfillment

Most of us working in the physician well-being space have adopted a model for professional fulfillment developed by our colleagues at Stanford.  If you care at all about your doctors’ professional health and how that impacts the care they deliver, I encourage you to read this article that describes their approach.  In it, they define efficiency of practice (eg team workflow, electronic health record use and misuse, systems bureaucracy), culture of wellness (institutional attitudes that advocate for self-care, peer support, and mutual compassion between team members and patients), and personal resilience (individual skills and behaviors that promote personal well-being) as the three mutually influencing factors that determine, for individuals as well as organizations, our overall professional health and well-being:

The many drivers of both burnout and high professional fulfillment fall into three major domains: efficiency of practice, a culture of wellness, and personal resilience… Each domain reciprocally influences the others; thus, a balanced approach is necessary to build a stable platform that will drive sustained improvements in physician well-being and the performance of our health care systems.

For the record, I fully concur with this approach, and with one of the authors whom I met at the international conference in Toronto, that the most important parts of the framework are the arrows reminding us always to look for how the domains intersect and influence one another.

We Are the System

In the article, the authors write, “Efficiency of practice and a culture of wellness are primarily organizational responsibilities, whereas maintaining personal resilience is primarily the obligation of the individual physician.”  This is where I differ somewhat.  I fully agree that an organization’s culture is set at the top.  Designated leaders lead by example, admit it or not, like it or not.  They (and we—all doctors bear this responsibility on any given care team) provide cues for acceptable and unacceptable behavior, positive and negative.

That said, a team or an organization’s culture is executed and manifested day to day, moment to moment, in every interaction, by each individual within the system.  This is the essence of complex systems—they are self-organizing at a global level (hence soon after joining a group we find ourselves adapting to fit in), and also emergent and evolutionary at the granular level (one person can turn a place around over time—have you seen it?).  So in my opinion, both leaders and individuals are responsible for creating and maintaining the Culture of Wellness in medicine.  We are the system.  If you’re interested in more of what I think about this, check out this podcast from September 2018 when I presented to the surgeons and anesthesiologists at the University of Wisconsin at Madison.

In a Complex System, It’s All About Relationships

A person is a complex system.  In my practice (and in my own life) I try always to attend to the relationships between 5 reciprocal domains (labelled intentionally after the Stanford model) of health: Sleep, Exercise, Nutrition, Stress Management, and Relationships.  How do they relate?  When I don’t get enough sleep I tend to overeat; when I eat too much I feel sluggish and unmotivated to exercise.  When I exercise less I am more susceptible to stress, which puts my relationships at risk, which then disrupts my sleep, and the downward spiral persists.

A patient care team, a medical practice, a hospital—these are all complex systems.  Besides the three domains in the Stanford model, what other factors contribute to the self-organizing nature of such systems?  Perhaps individual autonomy, collective loyalty, shared mission, attention to training, and communication?  What inter-relational factors dictate an individual’s or a subgroup’s behavior, and how does that influence the whole organization?

I am reminded of starlings in a murmuration, or sardines in a school.  Seen from afar, the mass of animals appears to move as one agile and sentient organism.  In reality, each animal’s movement is at once independent of and intimately tied to those in its immediate vicinity.  Each animal’s awareness of and response to its neighbors are acute and instantaneous, respectively, and thus the collective is able to evade predators and give humans insight into what true multi-mutual cooperation looks like.  They are attuned.  This is possible because, according to science:

The change in the behavioral state of one animal affects and is affected by that of all other animals in the group, no matter how large the group is. Scale-free correlations provide each animal with an effective perception range much larger than the direct interindividual interaction range, thus enhancing global response to perturbations.

Would your organization, seen from afar, appear as organized and fluid as a flock of murmuring starlings?  What would it require in order to do so?

* * * *

So what does this mean for my friend and how she (and we all) should think about doctors and our healthcare system in general?  How does this actually relate to solutions to the problems I presented last week?  Clearly, as I beat the long dead horse again and again, it’s about relationships, of course.  But we have to think more deeply than just about our behaviors and actions—we’ gotta buckle up and dive into their origins—spelunk our default orientations toward self and others, our automatic settings, and how they manifest in our relationships and create, intentionally and not, our collective systems.

Once again, I have hit 1000 words on this post and it’s late.  I’m getting there, I promise—not that I have the solution!  I’m simply learning and synthesizing more every week about how we can more consciously and mindfully approach the problem.  It has everything to do with the books I started reading recently about complexity, leadership, and mindset, and how they help me see my conversations and relationships in a new, exciting light.

More next week, friends!