200th Post: The Best of Healing Through Connection

Harper Columbine 5-31-14

Happy New Year, my friends!  May 2018 bring us all health, joy, connection, and learning!  And may we all look back one year from now feeling more empathy and compassion, and enjoying better relationships than ever before.

If you are new to this blog, welcome!  I hope you find something that resonates.  If you are an old friend, thank you for your support, feedback, and encouragement the last 32 months.  As I reread the last 199 posts this past week, my favorite parts were the thoughtful and enlightening comments.  I never imagined I could make friends writing a blog and yet here we are, connected, engaged, and holding one another up.

What have you discovered about your own writing when you go back and read?  Turns out I have a pretty consistent theme—it’s all about relationships.  Relationships require awareness, insight, active engagement, negotiation, and adaptation.  This is no less true in our relationships with ourselves than with others.  I have divided my favorite posts below into three categories: Health & Self-Care, Physician-Patient Relationship, and Relationships and Communication in general.  Though I have written pieces on politics and healthcare, I realize that these are critical arenas in which to explore relationships, and not my primary areas of focus in and of themselves.

2018 brings big new projects and responsibilities, yay!  So of course there will be big new challenges, also yay!  Looking ahead, I commit to my self-care practices with renewed motivation:

  1. Get to bed by 11:30 every night—Coach Christine has permission to call me out if I’m caught Facebooking past this time.
  2. Maintain 4+ workouts per week. An aging body needs regular vigorous movement!
  3. Keep up with therapy and resume regular coaching calls—reflect internally and project my best self outwardly.
  4. Maximize intake of stems, stalks, leaves, and fruit; minimize refined sugars.
  5. Nurture my ties to my tribes. They hold me up so I can do my best for those whom I lead.

The coming year will also require pulling back on certain things in order to maintain sanity.  While I refuse to renounce my Facebook use altogether, I have already decreased daily hours spent.  And though I still strive to maintain social/political awareness and activism, I will engage less with opposing voices on social media.  The costs, I have learned, far outweigh the benefits.  I would much rather take a politically oppositional friend out to lunch, or even fly to meet them, and have far more meaningful conversations in person.

For now, I plan also to scale back on the blog.  I’ll continue to write, of course, but likely more in the form of stream-of-consciousness journaling, brain-dumping, and snail mail letters to friends.  I expect that once in a while one of these activities will yield a post or two, and I hope to catch them by the tail and publish them before they escape the moment.  I leave here the list of my favorite posts to date.  Please feel free to dip in and out, leave new comments, and share links.  I suspect I will be drawn back to the page before long, as I already have a list of ideas for future posts.  But in case it’s longer than I anticipate, please know that I appreciate every view, every like, every comment, and every connection.

Thank you for stopping by and taking the time to read.  And may you take something away that makes you glad you came.

Sincerely,

Cathy Cheng


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Health and Self-Care

The Sh*tpile  /May 2015

https://catherinechengmd.com/2015/05/01/the-shtpile/

Everybody has one.  We inherit large parts of it from our parents, whose parents passed theirs down, etc.  Life experiences add mass and odor as we grow up.  It sits squarely in the middle of the house of our existence.  For the most part, we simply live our lives around it, walking past every day, careful not to knock any pieces off.  The surface gets dry and crusty; we grow accustomed to the smell.

 

How Health Begets Health  /November 2015

https://catherinechengmd.com/2015/11/07/how-health-begets-health/

As the kids and I sat waiting to get their flu vaccines this morning, I heard someone blow their nose. It was that thick mucus blowing that feels, at the same time, both gross and gratifying. I took a deep breath through my unobstructed nostrils and looked happily at my uninfected children.

 

Setting Intensions for 2016  /January 2016

https://catherinechengmd.com/2016/01/01/setting-intentions-for-2016/

This year I realized my body’s inevitable march toward menopause, a stark and sudden awareness. It came to me sometime in the spring, and I felt a keen jolt of motivation to prepare.   After 13 years of practice, I recognize two characteristics of women who suffer the least through this dramatic hormonal transition.

 

So You Want to Lose Weight  /March 2016

https://catherinechengmd.com/2016/03/12/so-you-want-to-lose-weight-the-four-as-of-goal-setting/

We set weight loss goals all the time, all of us—physicians included. We choose a number on the scale—an outcome—that represents our better selves, however we see it.  I suggest today that behavior-oriented goals, rather than outcomes-oriented ones, lead to far greater and more meaningful success.  How much are we really in control of what we weigh, day to day?

 

Never and Now  /April 2016

https://catherinechengmd.com/2016/04/17/atozchallenge-never-and-now/

And, there is another important practice to overcoming the Nevers: Mindfulness, the practice of the Now.  Never is about the future or the past.  Often it’s a shadowy, catastrophizing perspective of things.  But we cannot predict the future, despite our arrogant human certainty.  And we cannot live every day to come based solely on what has already happened or not happened.  Circumstances and attitudes change.  Landscapes change—at times literally, and in an instant.  We evolve, we learn, we grow.  How can we be so sure that Never is real?

 

Yes, And!  /April 2016

https://catherinechengmd.com/2016/04/30/atozchallenge-yes-and/

The goal is to open our minds, allow possibilities, expand our boundaries, and encourage creativity. I can still see her smile, the gleaming light of engagement and anticipation in her eyes.  I also remember my own hesitation and self-consciousness.  What do you mean, pimple on my forehead?  Is it really about to burst?

 

On the Critical Importance of Self-Care  /November 2016

https://catherinechengmd.com/2016/11/06/1638/

Technology and other advances have created a world of 24/7 hyper-stimulation, global comparisons of productivity and innovation, and immense pressures to be perfect, or at least appear so.  Men and women live under constant scrutiny and competition… I see, hear, and feel it from my patients every day—the anxiety, the uncertainty, the angst.  The suffering is real, if not totally tangible.

 

On the Second Arrow  /November 2016

https://catherinechengmd.com/2016/11/11/on-the-second-arrow/

Eventually, breathing, we can let go the negativity, pull the arrow out.  Breathe.  When assailed by another first arrow, see the second arrow coming and sidestep.  Breathe.  Keep breathing.  Practice self-compassion and forgiveness.

 

On Readiness  /November 2016

https://catherinechengmd.com/2016/11/16/on-readiness/

I confess I am guilty of impatience and judgment.  When I see your uncontrolled, lifestyle-related medical problems, and you resist behavior change, I feel frustrated.  I know you feel it, too.  But know that I don’t blame you. The point is: we don’t make changes until we are ready.

 

Walking the Talk  /July 2017

https://catherinechengmd.com/2017/07/09/walking-the-talk/

18 months ago I wrote about my plan for maximizing menopause preparedness.  As with so many missions, this one has experienced both successes and failures.

 

Just Do It My Butt  /November 2017

https://catherinechengmd.com/2017/11/06/just-do-it-my-butt/

Medical systems which include dieticians, exercise physiologists, and health psychologists can deploy these team members to support patients in their health journeys.  But does your doctor’s office have this kind of set up?  Does your insurance pay for these services?

 

Citius, Altius, Fortius!  /November 2015

https://catherinechengmd.com/2015/11/09/citius-altius-fortius/

Every day I live in awe of the astounding miracle that is the human body. It is the quintessential integrated machine.   Almost every part serves a unique and essential purpose in normal daily function, and the parameters for such function are incredibly narrow.  But take something out, wound something else, or trash multiple systems at once, and the whole assembly adapts around the insults, automatically, without any action or awareness on our part.  The body’s compensatory mechanisms exemplify the resilience and tenacity of nature, no doubt about it.

 

Dance For Your Health  /November 2017

https://catherinechengmd.com/2017/11/16/dance-for-your-health/

So basically, dancing activates key areas of the brain and body in an orchestrated fashion, igniting motion, joy, connection, exhilaration, sensory integration, creativity, passion, cardiovascular elasticity, and fun.  How could this not make us all younger?


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Physician-Patient Relationship

The Premise  /April 2015

https://catherinechengmd.com/2015/04/14/hello-world/

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.

 

What Are You Looking For?  /April 2015

https://catherinechengmd.com/2015/04/22/what-are-you-looking-for/

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?

 

More Than Enough Love  /June 2015

https://catherinechengmd.com/2015/06/20/more-than-enough-love/

Like parenting, the path of medical practice is not paved with lollipops and ice cream.  It’s more like an uphill dirt road with pits and grooves, erratic weather, and hairpin turns that make you dizzy and nauseated.  It can also offer astoundingly beautiful scenery along the way—like parenting.

 

Help Me Help You  /July 2015

https://catherinechengmd.com/2015/07/10/help-me-help-you/

When you feel that disconnect, like I have left Best Me somewhere else and you’re not getting what you need, what will you do?  Will you yell and storm away? Smile to my face and then write a scathing, anonymous Yelp review? What would you do if I were your spouse, colleague, friend, or child? You and I are in a relationship, not unlike these.

 

Closing the Satisfaction Gap  /July 2015

https://catherinechengmd.com/2015/07/20/the-thorn-in-our-collective-side/

This patient gave Dr. K the best possible feedback: An objective observation about a behavior, her subjective interpretation of it, and its consequence for their relationship.  This is how we communicate evaluations to medical students on their performance in clinical rotations.  There is no reason why it should stop at the end of training; it’s just that the evaluators have changed.

 

The Burnout Crucible  /September 2015

https://catherinechengmd.com/2015/09/20/the-burnout-crucible/

Maybe it’s a moot point, whether it’s better to never burn out or to burn out and relight. We’re all here doing our best every day. Maybe it’s more important to just cut ourselves and one another a little slack sometimes, have compassion for aggressors while calling out their unjust behaviors, and offer everybody the benefit of the doubt, especially when we’re all stressed out.

 

What Makes You Think You Can Trust Me?  /February 2016

https://catherinechengmd.com/2016/02/01/what-makes-you-think-you-can-trust-me/

Trust is the cornerstone of any meaningful relationship. The patient-physician relationship is no exception. It takes time and presence to cultivate. These are big investments, and if we are willing to make them, the returns can literally save us.

 

 

I am Edna Mode  /February 2016

https://catherinechengmd.com/2016/02/20/i-am-edna-mode/

Clearly, Edna trained in the School of Tough Love.  Fortunately for you, I have also studied empathy, compassion, and motivational interviewing.  I can help you persist.  I have patience for your journey.  I can be your pillar of consistency.  Edna is nothing if not consistent!

 

Humbling and Honoring  /April 2016

https://catherinechengmd.com/2016/04/09/humbling-and-honoring/

I get to choose when I am willing to donate my time and energy to the free clinic—everything I do there is on my own terms.  The patients there have no such choices.  If they want care, they have to show up—early—on the day the clinic is open, regardless of what else is going on in their lives.  There are no appointments, and almost no continuity with providers.  It’s a completely different world from where I make my living, on the Gold Coast of Chicago.

 

On Mutual Respect  /November 2016

https://catherinechengmd.com/2016/11/05/on-mutual-respect/

To Patients Who Abuse Medical Staff: Let me be clear: That is not okay.

 

No Substitute for Time  /November 2017

https://catherinechengmd.com/2017/11/03/no-substitute-for-time/

“More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in… physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.”

 

Dr. Jerkface In Context: Healing the physician-patient relationship  /November 2017

https://catherinechengmd.com/2017/11/25/dr-jerkface-in-context-healing-the-patient-physician-relationship/

Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.


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Relationships and Communication

Gratitude, Generosity, and Peace  /July 2015

https://catherinechengmd.com/2015/07/30/gratitude-and-generosity/

When I feel grateful, there is enough. I am enough. Even just saying the word, seeing it on the screen, brings me to a more peaceful state of mind and body.

 

Warrior Pride and a Plea for Kindness  /December 2015

https://catherinechengmd.com/2015/12/13/warrior-pride-and-a-plea-for-kindness/

There is no substitute for a face-to-face conversation, and the time and energy it takes to have one. It requires a certain degree of tolerance, and an unspoken contract of civility and courtesy.  We must choose carefully with whom we are willing to undertake such a venture.  And perhaps most importantly, we must be clear about our objective(s).  Do we really expect to change someone’s fundamentally held political or religious beliefs?  How realistic is that?  What other purpose, what other good, could possibly come from such conversations?

 

On Belay  /April 2016

https://catherinechengmd.com/2016/04/02/on-belay/

The interview starts with the two men talking about Hank Williams’ troubled life, his ‘formidable demons,’ as Hiddleston puts it. He expresses compassion for this, as I have seen him do in previous interviews about other characters he has portrayed.  He describes how Williams rose to stardom quickly, but ‘with no real support, no one to anchor him.’  Funny how he uses that word, anchor—like belayer.

 

Opposition and Openness  /April 2016

https://catherinechengmd.com/2016/04/20/atozchallenge-opposition-and-openness/

When I look at the list of definitions of oppose, I feel tired.  When I think of the energy it takes to constantly stand against something, I feel listless and drained.  Fighting, resisting, combatting, Obstructing, standing in the way, hindering, disputing, dissenting, contradicting—it’s exhausting.  I think of times when I meet someone new and all they talk about are the things they hate, that they can’t stand, that they want changed.  I cannot wait to get away and find levity.

 

Every Day a Revolution  /April 2016

https://catherinechengmd.com/2016/04/22/atozchallenge-every-day-a-revolution/

Like the turning of an incandescent light bulb, gently, patiently, and consistently in one direction, the steady work of activists eventually leads to sudden and intense illumination.  Darkness becomes light, cold spaces are warmed.

 

Withhold Judgment  /April 2016

https://catherinechengmd.com/2016/04/29/atozchallenge-withhold-judgment/

After all of this exploration, conversation, debate, research, and observation, once again I conclude that one of the most important practices for inner peace is to Withhold Judgment. Not all judgment, and not indefinitely, but much and for a while.

 

Playing My Part  /May 2016

https://catherinechengmd.com/2016/05/22/playing-my-part/

Given the awesome support network with which I am blessed, I feel an impulse to do something more with my writing—to amplify and project all this love and connection back out onto the world for some positive purpose.  But how can my words possibly make a difference?

 

Holding the Space for Personal Acts of Peace—On Listening  /July 2016

https://catherinechengmd.com/2016/07/11/holding-the-space-for-personal-acts-of-peace-listening/

I know I will not do justice to all the complexities of our issues in one blog post, but I ask your forbearance for my interpretation, as it has led me to greater conviction for what I can do, I, one person.

 

Holding the Space for Our Suffering to Heal Us  /September 2016

https://catherinechengmd.com/2016/09/22/holding-the-space-for-our-suffering-to-heal-us/

For a moment we felt stuck, we connection seekers.  I looked at our leader.  His expression conveyed nothing but humility and empathy.  His posture conveyed resolution.  Despite our deep longing, he refused to lead us into treacherously thorny fields, because he knew he did not have the time to bring us safely through to the other side.  But he also allowed us to process, invited us to consider how else we could collectively resolve our unease.

 

On the Golden Positivity Ratio  /November 2016

https://catherinechengmd.com/2016/11/25/on-the-golden-positivity-ratio/

I remembered something about healthy relationships maintaining a 3:1 ratio of positive to negative interactions.  Turns out it’s actually 5:1, widely attributed to observations by Dr. John Gottman, renowned marriage and relationship psychologist.  I think the same thing applies in other realms, too, such as self-talk—a reflection of our relationships with ourselves.  It’s not a far leap to see how this idea pertains to news, social media, and any other human interactions.

 

Train to Withstand the Discomfort  /February 2017

https://catherinechengmd.com/2017/02/20/train-to-withstand-the-discomfort/

We all know the satisfaction and comfort of echo chambers.  Seeing, hearing, and reading that which validates our existing positions feels so good.  But the farther we regress here, the harder it becomes to tolerate a dissenting view.  We must resist this temptation; we are called to be more disciplined than this.

 

To Train or Not to Train  /May 2017

https://catherinechengmd.com/2017/05/08/to-train-or-not-to-train/

…even if we don’t all talk politics, we all need effective communication skills, especially in the arenas of conflict resolution, negotiation, parenting (which encompasses them all), and the like.  We are social beings—we only survive by cooperating and living well within our tribes, and by tribes living well among one another.  That can only happen if we practice getting along.

 

Tribal Pride and Tribalism  /November 2017

https://catherinechengmd.com/2017/11/29/tribal-pride-and-tribalism/

We all need our tribes.  Belonging is an essential human need. To fit in, feel understood and accepted, secure—these are necessary for whole person health.  And when our tribes have purpose beyond survival, provide meaning greater than simple self-preservation, our membership feels that much more valuable to us.  But what happens when tribes pit themselves against one another?  How are we all harmed when we veer from “We’re great!” toward “They suck”?

 

 

 

I’m the Doctor, You’re the Doctor

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NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.

Hopey, Changey Hero Making

IVY Litt 11-8-17

NaBloPoMo 2017: Field Notes from a Life in Medicine, Day 8

Funny how I just wrote last night about connecting new dots to old dots.  It just happened again tonight!  A couple of weeks ago I responded to an online ad for an IVY Ideas Night with David Litt, author of Thanks Obama: My Hopey, Changey White House Years, entitled, “How to Inspire, Persuade, and Entertain.”  Litt was a senior speechwriter for President Obama, so I thought I could learn new tips for presentations, and feel a little closer to the president whom I miss so much.

I’ve done public speaking since eighth grade, when our speech teacher first taught us abdominal breathing and I discovered the thrill of holding the attention of a room full of people with only my words.  I work at an academic medical center and I hold zero publications, but my CV documents over 10 years of professional presentations to various audiences.  I thought I was pretty good at this speaking thing.

Three years ago I came across this TED talk by Nancy Duarte, whose ‘secret structure’ of great presentations I have used since I subsequently read her book, Resonate.  Essentially, she recommends that we invite audiences on adventure stories, create active tension between what is and what could be, and most importantly, make the audience the hero.  I have done this better and worse since then, but I always recognize the framework when I see it.  Those familiar with this blog know that I am also a fan of Simon Sinek, whose central message is that we perform at our best when we are crystal clear about our Why.  “People don’t buy what you do, they buy Why you do it,” he says.  Barack Obama employs both authors’ principles with eloquence and finesse, which I noticed reading We Are The Change We Seek, a collection of his speeches as president.  The best speeches delivered in this construction create audiences who are inspired, motivated, and empowered to hail a meaningful call to action.

Obama is could be core values

That’s basically what David Litt conveyed tonight.  When asked what advice he was given that served him best, he said, “Imagine someone in your audience will tell their friend tomorrow about your talk.  What is the one thing you want them to say about it?”  What is the Why of your talk?  Even though he no longer writes speeches for the most powerful person in the world, he expressed a desire to continue inspiring, empowering, and promoting personal agency in all whom his work touches. Make each and every audience member their own hero.

It turns out, however, that this approach applies to much more than public speaking.  On my 50 hour, 500 mile, aspen-pursuing weekend in Colorado last month, I described to my dear friend my favorite moments at work.  At the end of a patient’s day-long physical, after I have spent 90 minutes listening to their stories of weight gain and loss, work transitions and complex family dynamics, and reviewing their biometrics and blood test results, I meet with them for an additional 30 minutes to debrief.  This is when I present an integrated action plan compiled by the nutritionist, exercise physiologist, and myself.  It is a bulleted summary of our conversations throughout the day, centered on the patient’s core values and self-determined short and long term health goals, and crafted with their full participation.  I get to reflect back to my patients all that I see them doing well, and shine light on areas for potential improvement.  It’s an opportunity to explore the possible—to Aim High, Aim Higher, as the United States Air Force exhorts.  I often present the plan with phrases like, “Strong work!” “You’ got this,” and “Can’t wait to see what the coming year brings!”  My friend turned to me as we wound through autumn gold in the Rocky Mountains, a bit tearfully, and said, “You make them the hero of their own story.”  Yeah, I do, I thought, and I got a little teary, too.

Words are powerful.  They are our primary tool for relating to each other, for making another person feel seen, heard, understood, accepted, and loved.  You don’t have to be a public speaker or a presidential speechwriter to make a positive difference with your words.  At work, in your family, with your friends, with people on the street and in the elevator—what is the one thing you want someone to remember from their encounter with you?

No Substitute for Time

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NaBloPoMo 2017: Field Notes From a Life in Medicine

Day 3

How much time do you spend with your doctor each time you see them?  Is it enough?  If they had more time to spend with you, how would you use it?  Would it be better?

I’m too tired and it’s too late tonight to discuss the myriad factors that erode the patient-physician relationship, and thus our medical system in general.  But time comes to mind often for me, and I wonder if patients are as frustrated about it as I am.

Where I work now, I pretty much have as much time as I want with people.  It’s a sweet gig.  I can ask them about their work, their families, their interests.  I have time to listen to the answers, and even connect those with my observations about their health.  The most interesting parts of my interviews are the social history.  What do they spend their days doing at work?  What problems do they solve, who do they interact with, and what brings them meaning at the place where they spend the majority of waking weekday hours?  Then what do they do for fun, what’s life like outside of work?  I get to know my patients as individual, whole people, which I love, and that makes me look forward to every day at work with joy.

But time is not just good for me, for my professional fulfillment.   It’s good for patients, too.  When I spend time asking the important questions, putting together pieces of a person’s symptom puzzle, and do a directed exam, I’m more likely to come to a correct diagnosis and make an appropriate and specific care plan.  When I take the time to explain my rationale, decision process, and possible outcomes and follow up, my patients are more likely to feel seen, heard, and reassured.  They are more likely to stick with the plan and contact me if things change.  The next time they need help, they are more likely to call me and we have another chance to know each other better.

When the physician-patient relationship flourishes, we’re all healthier.

I love this article on The Health Care Blog, which essentially validates the time I take to talk to my patients.  My favorite line:  “More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in… physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.”

You may also be interested in this article, describing the origin of the 15 minute clinic visit, and why it really doesn’t make sense.

What do you think about physicians and patients advocating together to change this aspect of our flawed medical system? I know it’s complicated, requiring a hard look at our billing and compensation processes, as well as our productivity-driven, fee-for-service medical culture.  I still think it’s worth pursuing.  There is no substitute for time.  We must protect and defend it; our health depends on it.

Applying the Wisdom of Atticus Finch

Atticus_and_Tom_Robinson_in_court

“You never really understand a person until you consider things from his point of view—until you climb into his skin and walk around in it.”

–Atticus Finch

To Kill a Mockingbird, by Harper Lee

 

How do you practice and achieve empathy?  How do you notice others doing it?

It’s been on my mind a lot these last two weeks.  Current American politics resembles an interminable abscess, oozing ever more copious and putrid gobs of pus, from ever more unforeseen tracts of deep, diseased tissue.  How can we find any Healing Connection in the midst of all this?

Here’s my answer:  Role play and storytelling.

Role Playing Game Males Lego Duplo Play Build

 

Role Play for the Good

I used to hate role play, and now I jump at any chance to try it!  It all changed through a 7 week teaching workshop I did during my chief resident year, and I am forever grateful for the experience.  Now I regularly use role play to teach motivational interviewing, or MI, to medical students and residents.  Put simply, MI is a counseling technique that focuses on patient autonomy, and aims to reinforce intrinsic motivation for change.  My teaching method has evolved over time, due to my own unexpected experience of ‘climbing into the skin’ of others.

In the beginning I used to play the patient, letting students take turns practicing their MI skills on me.  After a couple of sessions I realized that even though I was pretending, I really felt like the students were earnestly trying to help me change my health habits, or making me feel bad about myself, depending on their proficiency.  So to give them the benefit of this perspective, I had them take turns playing both patient and physician.  The feedback revealed a richer, more insightful experience for all.

In 2015 I attended the Active Lives conference, where my technique was further enlightened.  I got to role play four times with a partner: first as patient, then physician, doing it the ‘wrong’ way (directive, authoritative, confrontational), and again in both roles doing it the ‘right’ way (collaborative, empathetic, nonjudgmental).  I felt the immediate contrast of the four roles emotionally and viscerally.  When all I heard from the doctor was, “Yes, I know you’re busy, but you have to find time to exercise,” and “Why don’t you do this…” and, “You should… You need to… If you don’t, then…” I felt absolutely no impetus to take any of this advice.  But questions like, “How important is it to you to…  How confident are you to… What would it take…what would need to happen in order for you to…” and, “What would life be like if…” invited me to explore possibilities, helped me to imagine and create my own future.  As an authoritative physician, I felt frustrated at my patient’s resistance to my evidence-based and well-intentioned advice.  By contrast, as a collaborative doctor, I feel freed to embark on an improvisational Yes, And adventure to reveal each patient’s personal path to healthier habits.  Now I offer my students the opportunity to experience all four roles.

I remembered this insight evolution last week when I came across a 1970 video of Jane Elliott’s classroom racism experiment.  She divides the class by eye color, asserts that blue-eyed children are better than brown-eyed children on one day, then reverses the premise the next.  While she makes privilege assignments that likely would not fly today, she also debriefs with the kids, helping them identify their assumptions, feelings, actions and reactions—much more authentically and directly than I think we are willing to do today.  She does it all without judging or shaming, pointing out biases and encouraging her students to examine them for themselves.  I admire her for pioneering this exercise, and I bet it affected her students in profound and lasting ways.

storytelling

 

The Importance of Story

Clearly, we cannot possibly depend on such academic practices to develop everyday empathy.  Luckily we now have infinitely easier access to one another’s stories than ever before, which is the next best thing.   Lately I feel a keen new appreciation of the importance of storytelling for conveying experience and stimulating mutual understanding.  Obligingly, the universe (read Facebook) has provided me with numerous testimonies of my fellow humans’ experiences and conditions, and this week they touch me even more acutely.  Here are some of them:

  • Former white supremacists talk about the importance of upholding others’ humanity, even as we denounce their beliefs.
  • A black writer recounts multiple instances of racism over her lifetime, inviting her white high school classmate to imagine and consider how they exemplify his white male privilege.
  • The head of neurosurgery at the Mayo Clinic in Florida tells his story of illegal, then legal immigration, and a subsequent life dream realized.
  • Neil DeGrasse Tyson shares stories of genitals on fire, educators’ responsibility to the electorate, pressure from his black classmate to contribute to ‘the black cause,’ realizing that he is doing just that, and why he wants to be buried instead of cremated (he has changed my mind, by the way).
  • David Duke’s godson credits the college friends who welcomed him despite his pedigree, with helping him defy and shed it.

 

What’s the Point?

The overarching goal here is to intentionally thwart the abstraction and dehumanization of people who are different from ourselves.  Stepping into another person’s shoes, ‘climbing into (their) skin,’ imagining how they feel, and actually feeling it—this is the best protection against bias, prejudice, and discrimination.  Empathy forms the sticky webs of connection that stymie the hymenoptera of hatred mid-flight, or catch us in the face and remind us to look where we’re going.  Where do we want our thoughts, words, actions, and relationships to take us?

I imagine a world of colorfully flawed humans, who acknowledge our biases openly and honestly; who recognize the risks that those biases carry; who accept ourselves, warts on soles and souls and all; who commit to a lifetime of extending that acceptance to one another; and who understand that it is our relationships, all of them, that kill us or save us.

So let’s play and tell—and feel and listen.  Really,  it’ll be good for all of us.

 

Only Love Can Win

Lily Pad Lake trail weather coming

Holy hell, what a week.  How are you feeling?  Most people I know express some combination of shock, resignation, rage, disbelief, hopelessness, gloom, and resentment.  I’m trying hard to practice Radical Acceptance.  It’s similar to the second arrow principle, in that at the very least, it lessens my own suffering from our collective circumstance.  But more than that, it allows me to focus more on what I will do, than seethe around my negative reactions.

I’m thinking of the Twitter account named Yes, You’re Racist.  Apparently the owner wants to identify the white supremacists who marched in Charlottesville, to publicly shame them and possibly get them fired from work. At least one person has lost his job based on a photo posted to the account.  What do you think about this?  I admit, my first reaction was positive.  Yes, call them out, make them accountable, I thought.  But then I wonder what good will this do?  Will the guy who got fired from the hot dog place suddenly think it was morally wrong to attend the march?  Or will he interpret his employer’s action as further proof that the liberal left conspires to restrict free speech and assembly, thereby deepening his animosity toward anyone who opposes his views from the left?  Will it open any space in his mind to consider why white supremacy is wrong, or help him acquire empathy or compassion toward any marginalized group?  Or won’t it just drive his racist expressions underground?  Doesn’t public shaming like this run the risk of re-closeting these people, so their grievances foment in the dark, only to be released again under pressure, in some act of overt violence?

I think about the fights between marchers and anti-protestors—between those who wish to incite violence, and those who succumb to the provocation.  To be clear, the Neo-Nazi, white supremacist marchers who descended on Charlottesville represent a vile and unacceptable set of ideas.  They are the villains.  And, fighting violence with violence is never a good solution.

So, we ask, what can we do?  How do we respond?  Maybe it’s because I’m on vacation this week, communing with nature in the mountains and watching the annual Perseid meteor shower from 10,000 feet, on a clear, literally stellar night, surrounded and awed by our millennia-old universe.  It keeps me from stalking Facebook quite so many hours a day, and gives good perspective.  I feel somehow more capable of saying, This is how things are.  It sucks.  It’s wrong.  And I can still make a difference.

In the end, I believe Only Love Can Win.  Blaming, shaming, belittling, and otherwise demeaning people for certain beliefs, actions, or associations—hating them—does not help.  What does help is offering compassion and empathy, and listening to understand.  I know I have said and written it many times, and I know many will argue that now is not the time to ‘get soft.’  But believe me, practicing love in the face of hate is anything but soft.  Let me share some resources that illustrate this, and that hold me up.  This is a very long post, and I hope you will stick with me ‘til the end.

Ai

Agape Love

Maria Popova, curator of the illuminating blog Brain Pickings, inspires me with her summary of Dr. Martin Luther King’s 1958 essay “An Experiment in Love.”  I refer to this article often since January 20.  Dr. King explores six tenets of nonviolent resistance (below).  It reminds me that while I vehemently oppose bigotry, racism, sexism, misogyny, xenophobia, and fascism, I can do it with a peaceful heart, full of love for humanity, and with faith that even my small contribution of said love can make a difference.  Here are the highlights of her piece, MLK’s words quoted:

  1. Nonviolent resistance is not passive cowardice. “For while the nonviolent resister is passive in the sense that he is not physically aggressive toward his opponent, his mind and his emotions are always active, constantly seeking to persuade his opponent that he is wrong. The method is passive physically but strongly active spiritually. It is not passive non-resistance to evil, it is active nonviolent resistance to evil.”
  2. The goal is connection. “Nonviolence … does not seek to defeat or humiliate the opponent, but to win his friendship and understanding. The nonviolent resister must often express his protest through noncooperation or boycotts, but he realizes that these are not ends themselves; they are merely means to awaken a sense of moral shame in the opponent. The end is redemption and reconciliation. The aftermath of nonviolence is the creation of the beloved community, while the aftermath of violence is tragic bitterness.”
  3. Separate the people from problem (as William Ury et al would say). “The attack is directed against forces of evil rather than against persons who happen to be doing the evil. It is the evil that the nonviolent resister seeks to defeat, not the persons victimized by the evil… [Regarding racial injustice:] We are out to defeat injustice and not white persons who may be unjust.”
  4. Be prepared to pay the cost. “The nonviolent resister is willing to accept violence if necessary, but never to inflict it. He does not seek to dodge jail.”
  5. Manage thyself. Do not allow yourself to descend to the depths of hate while you fight hate itself.  Cultivate love instead.  “The nonviolent resister not only refuses to shoot his opponent but he also refuses to hate him. At the center of nonviolence stands the principle of love…To retaliate in kind would do nothing but intensify the existence of hate in the universe. Along the way of life, someone must have sense enough and morality enough to cut off the chain of hate. This can only be done by projecting the ethic of love to the center of our lives.  This is Agape love…  Agape means understanding, redeeming good will for all men. It is an overflowing love which is purely spontaneous, unmotivated, groundless, and creative… Another basic point about agape is that it springs from the need of the other person… The Negro must love the white man, because the white man needs his love to remove his tensions, insecurities, and fears… Agape is not a weak, passive love. It is love in action… Agape is a willingness to go to any length to restore community… It is a willingness to forgive, not seven times, but seventy times seven to restore community.”
  6. Hope.  “Nonviolent resistance … is based on the conviction that the universe is on the side of justice. Consequently, the believer in nonviolence has deep faith in the future. This faith is another reason why the nonviolent resister can accept suffering without retaliation. For he knows that in his struggle for justice he has cosmic companionship.”

moths on poop

10 Ways to Fight Hate

One of the first pieces I read after the events on Saturday was this article from the Southern Poverty Law Center, listing ten ways to fight hate.  So while I carry that peaceful heart full of Agape love, these are the concrete things I can do right now (highlights quoted):

“The good news is, all over the country people are fighting hate, standing up to promote tolerance and inclusion. More often than not, when hate flares up, good people rise up against it — often in greater numbers and with stronger voices.”

  1. Act
  2. Join Forces
  3. Support the Victims
  4. Speak Up

“Do not debate hate group members in conflict-driven forums. Instead, speak up in ways that draw attention away from hate, toward unity.

“Goodness has a First Amendment right, too. We urge you to denounce hate groups and hate crimes and to spread the truth about hate’s threat to a pluralistic society. An informed and unified community is the best defense against hate.

“You can spread tolerance through social media and websites, church bulletins, door-to-door fliers, letters to the editor, and print advertisements. Hate shrivels under strong light. Beneath their neo-Nazi exteriors, hatemongers are cowards and are surprisingly subject to public pressure and ostracism.

  1. Educate Yourself

“Most hate crimes…are not committed by members of hate groups; the Southern Poverty Law Center estimates fewer than 5 percent. Many hate crimes are committed by young males acting alone or in small groups, often for thrills. While these perpetrators may act independently, they are sometimes influenced by the dehumanizing rhetoric and propaganda of hate groups.”

  1. Create An Alternative

“Do not attend a hate rally. As much as you might like to physically show your opposition to hate, confrontations serve only the perpetrators. They also burden law enforcement with protecting hatemongers from otherwise law-abiding citizens. If an event featuring a hate group, avowed separatist or extremist is coming to your college campus, hold a unity rally on a different part of campus. Invite campus clubs, sororities, fraternities and athletic organizations to support your efforts.

“Every act of hatred should be met with an act of love and unity. Many communities facing a hate group rally have held alternative events at the same hour, some distance away, emphasizing strength in community and diversity. They have included forums, parades, and unity fairs featuring speakers, food, music, exhibits, and entertainment. These events give people a safe outlet for the frustration and anger they want to vent. As a woman at a Spokane, Washington, human rights rally put it, “Being passive is something I don’t want to do. I need to make some kind of commitment to human rights.”

  1. Pressure Leaders

Form relationships with community leaders before a hate incident occurs.

Encourage leaders to name the problem.

Push leaders when they show bias or fail to act. [And do it respectfully—ad hominem never helps.]

  1. Stay Engaged
  2. Teach Acceptance

“Bias is learned in childhood. By age 3, children can be aware of racial differences and may have the perception that ‘white’ is desirable. By age 12, they can hold stereotypes about ethnic, racial, and religious groups, or LGBT people. Because stereotypes underlie hate, and because almost half of all hate crimes are committed by young men under 20, tolerance education is critical.”

  1. Dig Deeper

“Look inside yourself for biases and stereotypes.

“We all grow up with prejudices. Acknowledging them — and working through them — can be a scary and difficult process. It’s also one of the most important steps toward breaking down the walls of silence that allow intolerance to grow. Luckily, we all possess the power to overcome our ignorance and fear, and to influence our children, peers, and communities.”

VICE screenshot

Breathe Deep, Stay on the Path, and Engage

How would you confront a white supremacist in person, face to face?  Would you share a meal with him/her?  I saw this video clip on Facebook, of a young Chinese-American man, Eddie Huang, sitting down to dinner with Jared Taylor, an older, white nationalist man, and founder of American Renaissance, to discuss Taylor’s perspective.  The American Renaissance site espouses genetic differences in intelligence and the propensity to commit crimes between races, among other things.  Taylor states that historically, Europeans have “killed more people per capita” than any other group, and attributes this to them being “more technologically advanced.”  He voted for 45 because his policies would “slow the dispossession of whites in America.”  He says he wants to keep whites a majority in the United States, or else they “no longer control our own destiny.”

I imagined myself in Eddie’s shoes, and I could not fathom how I could stomach this conversation while eating.  Actually I think he stops, while Taylor continues to eat—Chinese food.  I don’t know anything about Eddie Huang other than what I see in this video, and I admire him.  He sits down and engages respectfully, thoughtfully, and firmly, with a person who basically thinks he does not deserve to be an American.  Could you do that?  I’m not sure I could.  And what would the world be like if we all trained to do exactly this?

Thank you for reading to the end.  My point here is that we can oppose and resist more effectively than with rage, shame, and violence.  I know I won’t make everybody put down their clubs and fists with my small words, but this is where I stand, and I commit to speaking my stance as much and as loudly as possible.  I pledge to do my best always to profess what I am for, more than what I am against.  I commit to a practice of Agape love, Radical Acceptance, Mindfulness, and Peaceful, Respectful Activism.  I would love your company on this journey.

 

Love You Into Being

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A couple of weeks ago I met my new medical students.  These 10-12 trainees will be my small group for the next two years.  We will meet monthly to discuss the soft stuff of medical training—hierarchy, tribalism, death and dying, medical errors, difficult patients, etc.  Some call it “third year medical student support group.”  This is my 6th year of the pleasure and privilege (I inherited my first group halfway through, when their previous preceptor moved out of state).

With each successive group I am ever more amazed at the students’ level of insight.  They articulate compassion, humility, and maturity that I don’t think I had at their level of training. Or maybe it’s because we did not have classes like this to explore such things when I came up (or maybe I don’t remember?).  More and I more I see my role as facilitator more than teacher.  I am not here to impart medical knowledge.  Rather, it is my job to stimulate exploration, conversation, and meaning.  It’s so freeing, really—there is no standardized test to teach to.  And yet I see it as my responsibility to help prepare these gifted young people to face the greatest challenge and reward of the profession: human relationships.

I feel no fear or trepidation.  We cannot ‘fail’ at this class, any of us.  Because the point of it is simply for everybody to participate, contribute, consider, and learn—myself included.  Each month the students are given questions to answer in the form of a blog post.  For example, “Recall an example of inspiring or regrettable behavior that you witnessed by a physician.  Describe the situation, and its impact on you, the team, and/or the patient.”  I read them all and facilitate discussion, tying together common themes and asking probing questions.  My primary objective is to help them maintain the thoughtfulness and humanity that led them to medicine in the first place.  Medical training has evolved in the past 20 years, for the better in some ways, not so much in others.  One way we do much better nowadays is recognizing the hidden curriculum, and shining light on its effects, both positive and negative, through classes like this.

We all have those teachers who made a difference in our lives—or at least I hope we all do.  I have multiple: Mrs. Cobb, 4th grade; Mr. Alt, 7th grade math; Ms. Townsend (now Ms. Anna), 7th grade English; Ms. Sanborn, 7th grade social studies; Mrs. Stahlhut, 9th grade geometry; Mrs. Summers, 10th grade English; Coach Knafelc, varsity volleyball; Dr. Woodruff, primary care preceptor; Dr. Roach, intern clinic preceptor; Dr. Tynus, chief resident program director.  My mom is one of these teachers, also.  She leads nursing students in their clinical rotations.  I have seen her student feedback forms—they love her.  And it wasn’t until I heard her talk about her students that I realized why they love her and what makes her so effective—she loves them first.  Teaching is often compared to parenting.  Our parents, at their best, see our potential and love us into our best selves.  They cheer us, support us, redirect us, and admonish us.  They show us the potential rewards of our highest aspirations.  If we’re lucky, they role model their best selves for us to emulate.

All of my best teachers did (do) this for me.  I’m friends with many of them to this day, and I still learn from them in almost every encounter.  I love them because I feel loved by them.  They held space for my ignorance and imperfections.  I always knew that they knew that my best self was more than the last paper I wrote, the last test I aced, or the last patient encounter I botched.  To them, my peers and I were not simply students.  We were fellow humans on a journey of mutual discovery, and they were simply a little farther along on the path.

This is my aspiration as a teacher, to live up to the example of all those who loved me into the best version of myself today.  This kind of love allows for growth and evolution, from student to colleague, to friend, and fellow educator.  This is not something attending physicians typically express to medical students, positive evolution of medical education notwithstanding.  But when I met this new group, I was overcome by love for them.  So I told them.  “If you take away nothing else from our two years together, I want you to have felt loved by me.  I wish to love you into the best doctors you can be.  That is my only job here.”  Or something like that.  It was impulsive and possibly high risk.  But it was the most honest thing I could say in that moment, my most authentic expression of my highest goal for my time with them.  I only get to see them once a month, and I want them to be crystal clear about what I am here to do.  We have lots to cover these two years, so much to learn and apply.  And love is the best thing I can offer to hold us all up through it.