An Early Resolution

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NaBloPoMo 2017: Field Notes from a Life in Medicine—Last Post

It’s December 1 here in Chicago, but I have almost 2 hours before midnight in California, and 5 hours in Hawaii, so I’m still counting this post as on time.  Meh whatever, it’s my blog and I can do what I want—last post for NaBloPoMo 2017, woo hoooooooooo!!

Okay so, when was the last time you gave another driver the finger?  I can’t even remember myself, maybe high school?  Definitely by the end of college I had stopped, and I can honestly say I probably only ever did it a handful of times.  In college I was in a car with friends and the driver cheerily wagged his finger at another car that had cut us off.  He didn’t get angry, but rather acknowledged the rudeness with humor.  At least I thought it was humorous.  So I’ve been doing it ever since—but with varying degrees of good humor.

Last week I was driving to work (you know what’s coming).  As I approached an intersection about 1.5 car lengths behind the sedan in front of me, where we had no stop sign but the cross street did, I could see a car inching out at the corner.  I anticipated that it would try to make a turn after the car in front of me passed, thereby causing me to have to slow down.  Sure enough that’s what happened, and I wagged my finger.  I suppose my intent was to shame, I’m embarrassed to write.  If I were that driver, I might have felt ashamed, and also annoyed at the gesture.  He, in turn, showed me a stiff, straight middle finger, accompanied by an unmistakable expression of the very same message—eye contact and all.

That hurt my feelings, I’m also embarrassed to report.  Not quite sure why I’m embarrassed—because I kind of deserved it, or because we’re not supposed to let stuff like this get to us?  Whatever, it felt bad and I didn’t like it.  After reflecting over the next mile or so, I decided that from now on I will simply treat other drivers with kindness first, regardless of the crazy antics they perpetrate on the roads (and let me tell you, in Chicago it can get pretty crazy).  That is the resolution that makes me feel the best.  And now I’m even more embarrassed and ashamed because this is pretty much how my mom treats all drivers (all people, really) since I can remember.  Well, better late than never.

I’m trying to remember how I came to this conclusion, because it took like quick-drying super glue, and I have abided by it firmly ever since.  I tried to imagine myself in that driver’s place.  What would make me in such a hurry that I would intentionally inconvenience another driver, who has the right of way, to get going just a few seconds sooner?  Was he really late for work, or to see a sick relative in the hospital?  Was he just an impatient driver in general?  Regardless, was my finger wagging helpful to either of us?  Would it make him less likely to do the same thing again?  Maybe it would have been better if I had waved, offered some grace and generosity of spirit?  If I were him, I would certainly appreciate that more than a pompous finger wagging.

Exercising patience and generosity on the roads is easier said than done, though, am I right?  Surely I cannot be the only one challenged by this?  Now that I think more about it, maybe my embarrassment at feeling hurt by his gesture relates to the fact that society tells us in a lot of ways that we’re not supposed to treat other drivers as human—and thus not be affected by them.  Jockey for position, don’t let ‘em in, fuck ‘em.  Stupid gestures should mean nothing, because we’re simply expected to treat one another like garbage.  It feels like this when I let someone in my lane and they don’t wave.  No acknowledgement, no appreciation.  That doesn’t feel good, and it’s not who I am.

Long ago I realized that I almost never need to get anywhere so urgently that I need to cut people off or risk my safety, or that of my passengers, in the car.  Whenever I see someone signaling to get in my lane, I almost always make space for them.  I try to avoid entering intersections I cannot clear, because I hate when cars do that and cause gridlock, especially at rush hour.  But somehow I didn’t see the finger wag as contrary to these other acts of driving courtesy—in this respect I guess I was stuck in the ‘fuck ‘em’ mentality.  So it makes sense that after experiencing the other side, and so emphatically, I realized that the only thing to do for my integrity is to reject that behavior altogether.

So, no more finger wagging.  Maybe I’ll take a deep breath and find some other, more neutral expression?  It feels necessary to acknowledge my own frustration, but not necessarily to project it on the other person.  Maybe I need a mantra.  *Deep breath* “You be safe now.”  *Deep breath* “You do you, I’ll do me.”  *Deep breath* “Thank you for not hitting me.”  *Deep breath* “I remind myself that you are a fellow human being, and we are all here doing the best we can.”  Maybe a more succinct version of that last one.  I’ll work on it.  I’m sure I’ll be working on it for a long time yet.

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Thanks to all who have read along this month, it’s been fun!  Now onto holiday cards, each of which I will once again attempt to write by hand this year.  It just feels like the right thing to do, and I get to break out my fun colored pens.  In case I don’t make it back in time, Happy Holidays to all, and best wishes in 2018 and beyond!

Comfort Food

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NaBloPoMo 2017: Field Notes from a Life in Medicine

There is just something about rice that comforts us Asians.  This morning I got up early and spent all morning with my hosts in the Department of Surgery.  My presentation went well, as did a leadership and communication session I helped lead with the department chair.  But I only snacked on trail mix, and by the time I met my friend for sushi in the afternoon, I was starving.  The tuna, salmon, and yellowtail sashimi came with a nice, round bowl of rice, and I was in heaven.  The smooth, cool texture of the fish, the pungent bite of wasabi, and the dampening, flavor blending effect of soft white rice—every bite was a true pleasure.

Coming back from the west I connected in Denver, happily landing at Concourse C, where they have a bank of restaurants serving hot food.  I never do this, but tonight I made a beeline for Big Bowl.  No burgers, wraps, salads, snack boxes, or tabouleh this time.  I wanted rice and stir fry.  They served up one of those black takeout containers with the clear lids, filled with food, and I ate the whole damn thing.  It was just so satisfying, and so odd because Chinese food is usually the last thing I want when I eat out.

Maybe it’s because I’m overtired.  I traveled three times in three weeks in October, to Colorado, then San Francisco, then DC.  I connected with amazing people, old friends and new, and my brain was saturated with nature, love, and learning.  I also had multiple projects going on at home in that time.  This month I have stuck with my commitment to post here every day save one, keeping me up too late most nights.  I have presented to colleagues twice, traveling once to do it.  It’s been four weeks since I hurt my knee (complete ACL tear, now confirmed, with minor meniscal tears associated), I’m still limping, and my left quad is visibly–stunningly–atrophied.  All in all, it’s been a physically, mentally, and emotionally grueling couple of months.  I don’t regret most of it, except maybe going to volleyball that night when I probably should have gone to bed.  Grrr.

So it makes sense tonight that I’m attracted to ramen with a poached egg, chicken and vegetable soup, rice, stir fry, and oily fish.  They are warm, substantive, and satisfying, without feeling heavy or gluttonous.  I don’t feel guilty after eating them—these are my true comfort foods.

Thankfully, I have no more travel until Christmas and no presentations for two months.  One more NaBloPoMo post tomorrow and 2017 is in the books.  I’ve accomplished a lot, and definitely enough, this fall.  I can get off this treadmill in another day or so, and start the knee rehab in earnest—a whole new and fascinating experience!  Patience will be the challenge, perseverance the goal, and mindfulness the primary coping tool.  Now I just need to get home and get some sleep.

Tribal Pride and Tribalism

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NaBloPoMo 2017: Field Notes from a Life in Medicine

What tribes do you belong to?  How do they serve you, and you them?  How not?

I think of this today as I have traveled out of state to speak to a Department of Surgery on physician well-being.  I wonder how often they have internists present at their Grand Rounds?  What a tremendous honor, I’m so excited to be here!  I hope my talk will be useful and memorable, as I represent my field and my institution, in addition to myself.  In the talk I describe the central tenets of Tribal Leadership and culture, and how to elevate ours in medicine.

So I’m thinking tonight about tribal pride and tribalism—the benefits and risks of belonging.

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”?

Of course I’m thinking now of intra-professional tribalism:  Surgery vs. Medicine vs. Anesthesia vs. OB/gyne vs. Psychiatry.  Each specialty has its culture and priorities, strengths and focus.  Ask any of us in public and we will extol each other’s virtues and profess how we are all needed and equally valuable.  Behind closed doors, though, internists will call orthopods dumb carpenters; surgeons describe internists’ stethoscopes as flea collars, and the list of pejoratives goes on.  Maybe I’m too cynical?  My interactions with colleagues in other fields are usually very professional and friendly—until they are not.  I have experienced condescension and outright hostility before.  But can I attribute it to tribalism—that general, abstracted “I’m better than you because of what I do” attitude—or to individual assholery?  Or maybe those docs are just burned out?  As with most things, it’s probably a combination.  Based on what my medical students tell me, negative energy between specialties definitely thrives in some corners of our profession.  Third year medical students are like foster children rotating between dysfunctional homes of the same extended family—hearing from each why all the others suck.

So what can we do about this?  Should we actively police people’s thoughts and words in their private moments?  I mean part of feeling “We’re Great!” kind of involves comparing ourselves with others and feeling better than, right?  Isn’t some level of competition good for driving innovation and excellence?  Should we even embrace this aspect of tribal pride?  It certainly does not appear to be diminishing, and I have a feeling it’s just human nature, so probably futile to fight it.

I wonder why we have this need to feel better than.  Is it fear?  A sense of scarcity?  As if there is not enough recognition to go around?  Like the pie of appreciation is finite, and if you get more I necessarily get less?  Intellectually we recognize that we are all needed, we all contribute.  But emotionally somehow we still feel this need to put down, have power over, stand in front.  And it’s not just in medicine.  I see it in men vs. women, doctors vs. nurses, liberals vs. conservatives, and between racial and ethnic groups.  It makes me tired.

But maybe we can manage it better.  Maybe we can be more open and honest about our tribal tensions, bring them into the light.  Yes, I think surgeons can be arrogant.  And that’s okay to a certain extent—it takes a certain level of egotism to cut into people, and when things start going wrong in the OR, I think that trait can help make surgeons decisive and appropriately commanding when necessary.  I imagine surgeons get impatient with all the talking we internists engage in.  So many words, so little action, they might think.  And yet they understand that words are how we communicate with patients, how we foster understanding and trust.  Maybe we can all do a better job of acknowledging one another’s strengths and contributions out loud and in front of our peers (and learners).  The more we say and hear such things, the more we internalize the ideals.

Tomorrow I get to spend a morning with surgical attendings and residents.  I hope to contribute to their learning during my hour long presentation, but I really look forward to my own learning, to expanding my understanding and exposure to parts of my profession that I don’t normally see.  I’m humbled at the opportunity, and I will look for more chances to bring together colleagues from divergent fields.  If we commit, we can connect our tribes and form a more cohesive profession.  That is my dream for future generations of doctors—to be freed from infighting and empowered to collaborate at the highest levels, for the benefit of us all.

 

Mom Love

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Somehow tonight I got to thinking about all my patients who are moms.  I am filled with love and admiration, and compassion for all of them.  Maybe it was because today that is what I did most—momming.  Chauffer, meal planner, shopper, meal preparer, science project thingy seeker, organizer of the week to come (meal planner, babysitter/transport arranger, meal planner, shopping planner, piano lesson re-scheduler)…

I feel so grateful that I can work part-time.  I accomplish most of these life tasks on days when I’m ‘not working,’ as I used to say.  Now I call them days on which I ‘don’t see patients.’  All moms work; it’s a full time job with intangible and transcendent benefits, as well as hellish hours, often disproportionately low appreciation, and obviously no financial compensation.  Some of you may have seen a popular article this year on the mental workload of moms.  I highly recommend the short read.  Here’s a slightly older article that also includes references to research on the ‘work-home gender gap.’  And I absolutely love this eloquent, hilarious, and heartfelt to tribute to moms from last year, which is basically encapsulated in the first sentence: “I am the person who notices we are running out of toilet paper, and I rock…”

What tugs at my heart the most sometimes are the moms who have chosen to stay at home, giving up, at least temporarily, a fulfilling and meaningful professional career.  So many of them feel conflicted over making this choice, and then shame over feeling conflicted.  Countless times I have heard some version of, “Please don’t think I don’t love my kids, because I LOVE my kids!  …But (sheepishly) being with them 24/7 is so tiring, and I really miss using those other parts of my brain, having conversations with adults, and solving problems that employ my education and training.  But I love my kids, really I do, and I love being with them and I chose this and I know I should feel so grateful that we can afford for me to stay home, I just feel so guilty for ever wanting to be away from them, what good mom wants that??  But I’m so tired, and sometimes (pause) I wonder if I should have kept my job, worked it out somehow?  I never thought I would feel so torn.”  In these encounters I do my best to validate my patients’ choices, to reassure them that in no way do I question their love for their children just because they long for the company of peers and colleagues, and to address the consequences of their inner conflicts on their health and relationships—with self and with others.  I feel sad and angry that anyone would shame a mom for wanting to have a meaningful life outside of momming.

There’s the guilt of the working mom, also—which springs from the same pathological thinking that no good mom would want to be away from her kids.  But somehow these women seem easier to console, in my experience.  They often derive significant meaning from their work, and even if that is not the case, they take pride in providing for their families.  They also often report seeing themselves as role models for their daughters.  Regardless, I hate that these women have to deal with the same social gremlins as their stay-at-home counterparts—that somehow being a mom and having a career are necessarily divergent ideals.  This is an example of a false dichotomy that serves no useful purpose, and causes many of us to suffer unnecessarily.  Thankfully, others have written extensively on solutions; I really like this article on 8 ways to overcome mom guilt, regardless of your W2 status.

In looking up the articles for this post, I also came across this one, addressing the invisible mental workload of men.  I’m so glad I read it, because it reminds me of another fallaciously dichotomous rabbit hole: when we start exploring and addressing women’s challenges, the discussion too easily devolves into man-hating.  I claim my own susceptibility to this mindset, and thankfully this article helps me rein it in.  The same antiquated social pressures that tell women they ‘should’ always want to stay at home also tell men that they ‘should’ always want to be at work, and GAAAGH, it just kills all of our souls, a little at a time.  The author, Josh Levs, writes:

“All women who notice and keep track of their families’ many needs deserve big props and respect for it. So do the men who do this work. It’s crucial, detail-oriented, and never-ending. It makes a home a home.

“For 2017, let’s resolve to put aside misguided gender assumptions and work together to achieve a better balance and healthy work-life integration—for the sake of women and men.”

I wholeheartedly agree.  Let us stop with the guilt trips and shaming, and give all moms, and dads too, all our love for the ‘momming’ we all do!

 

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.

Because This Is Who We Are

 

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Followers of this blog may know of my interest in and passion for physician health and well-being.  I was immersed in this world last couple of months, with two amazing conferences and multiple conversations with fellow physicians at work.  As often happens, I was moved to articulate a vision/mission statement of sorts, mostly to solidify my own intentions and also to share with like-minded colleagues.

I love that I enter this arena from the world of executive health.  Corporate leaders, physician leaders, and physicians on the ground share so many attributes that everything I learn from patients translates seamlessly to my own professional development.  This is exactly the right space for me to inhabit today, and I am forever grateful for the integrative experience.  Physicians are care team leaders by default, and we miss opportunities to improve all of medicine when we forget or ignore this fact.  I’m interested to know your response to the words below—the more visceral the better (but please, if possible, refrain from spitting, vomiting, or defecating your own words here):

Why do we advocate for physician health and well-being? 

Because we believe we can only lead well when we are well ourselves.

Because leading can be lonely and leaders need support.

Because leaders need metrics of our own performance, both related to and independent of the performance of those whom we lead.

Because health and leadership intersect inevitably and who we are is how we lead; the more awareness and active, intentional self-management we practice, the more effective leaders we will be.

Because people follow our example, like it or not, so we owe it to ourselves and those we lead to model Whole Physician Health.

What Is Whole Physician Health?

Whole Physician Health is an approach to health and well-being which defines physician as both clinician and leader, both healer and vulnerable.  This approach focuses on the 5 Realms of Health: Nutrition, Exercise, Sleep, Stress, and Relationships.  We explore how these realms intersect and overlap, affecting the individual physician, those whom the physician cares for and leads, and the entire medical profession.  We apply principles from health and sports psychology, communication, leadership, mind-body medicine, and myriad other disciplines.  We value openness, curiosity, critical analysis, and collaboration.  Our mission is to create a resilient medical culture in which all members—physicians, patients, all caregivers and support personnel—thrive and flourish.

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The Whole Physician Health Advocate:

*Values self-awareness and self-exploration.

*Understands and accepts his/her position as role model and culture setter for the team.

*Wishes to broaden the skillset in cultivating positive relationships

  • With self
  • Between self and immediate colleagues
  • Between colleagues themselves
  • Between physicians and staff
  • Between teachers and learners
  • With extended family of colleagues and institutional entities
  • Between institution and the patients it serves

*Sees the physician health and well-being movement as an opportunity to learn, see from a different point of view, connect to fellow physicians, and form new tribal bonds that will hold us all up.

*Wants to contribute to the creation of a global professional vision and mission of the 4 WINS:

WIN 1–You

WIN 2–Those you lead

WIN 3–Your whole organization

WIN 4–All those whom your organization touches

Of note, one need not be a physician to advocate for Whole Physician Health.

You Can’t Pee!

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NaBloPoMo 2017: Field Notes from a Life in Medicine

When my son was little we lived in an apartment where the kitchen was a separate room, with only a small window through which I could see what he was doing in the living room while I cooked.  Once when he was about five months old, I looked out and he was lying on the mat in the middle of the floor, playing happily with the toys dangling from arches overhead.  I swear I only turned around for a minute, and when I looked back he was gone.  Empty mat, toys still dangling, no kid, no sounds.  I can’t remember what I was doing, but it felt like a slow motion eternity getting out of that damn kitchen to find him.  Something heavy must have fallen on him or he was otherwise suffocating or dying, for sure.  …He had just learned to roll over, and he had rolled and rolled and rolled himself into the space under the air conditioning unit near the window.  He was turning over a dried jasmine leaf he’d found on the floor.  Not long after that I decided I had to buy food preparation gloves.  Just in case my kid needed me anytime I was handling raw meat, this would save me the infinitude of time it would take to wash my hands—I could just pull the gloves off and bolt!  Because you know, 30 seconds could mean life or death for a toddler in his own living room.

Please laugh—I did today when I told the story to a friend.  It came up as we explored the phenomenon of moms putting everything for their kids before themselves.  We compared notes on how long we had ever held our urine.  What mom has not done this?  You can’t pee!  Because you never know which minute you’re not with your children will be the one during which your neglect will kill them.  Thankfully children grow and become more independent, and we can free our bladders again eventually.

It’s not just moms, though.  One of my teachers in the hospital gave herself a urinary tract infection as a resident.  She had so much to do every day, so many patients who needed her that she felt guilty taking time to pee.  I did the same thing in clinic for many years.  I could not justify making patients wait another minute when I was already 15 (usually more) minutes late seeing them. I don’t do this anymore.  In a fit of efficiency last week, I stepped into the restroom after I set my lunch to microwave for 2:00.  It literally takes only a minute to pee.  I don’t usually run late these days, but even if do, now take care of my needs first.  It’s better for me, and better for my patients, whose doctor is not distracted by preventable physical discomfort and dying to end the interview or exam to get some relief.

Our culture still expects moms, doctors, nurses, teachers, and many others to sacrifice selflessly in service of our charges.  UTIs are the least important consequence.  Over 50% of physicians in the US report at least one symptom of burnout, and 400 doctors kill themselves annually.  That is the equivalent of my entire medical school, dead, every year.  It’s not all because of the job, but the obligatory selfless-giver mentality in medicine definitely contributes.

So whatever helping profession you are in, please take time to take care of yourself.  We need you whole and healthy to take care of the rest of us and our children.

Go pee.  I will wait.