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, 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!

Attune and Attend

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My friends, I am offended.  I’m insulted and frustrated.  Part of me screams, stomps, and rages inside.

I am embarrassed.

My friend went to establish care with a new primary care physician last week.  Before the appointment she was told to bring all of her medical records.  No instructions, no specification of which parts or in what form.  So, being the tech-savvy and eco-friendly woman she is, she downloaded all that was available to her onto a thumb drive, as it was rather copious now in her 7th decade of life.

Upon arrival, she presented the drive to the woman who initiated the evaluation.  She thinks this was a nurse; but she’s not sure.  The woman said she could not ‘handle’ the thumb drive, but said, “I can just pull it up here online.”  What?  Ok whatever, clearly the medical record request was simply a routine request made of all new patients.  Thereafter the woman proceeded through routine medical questioning.  But as my friend answered the interrogation, she felt distinctly ignored.  Her concerns were not addressed and she did not feel any rapport.  The woman did an EKG and left the exam room.

Later, while my friend was still sitting on the exam table, the woman returned with an old man in a white coat.  He stood there, hands behind his back, and informed my friend they had called for an ambulance to take her to the emergency department.   The EKG showed an abnormal heart rhythm.  They said she would likely be in the hospital for two days for observation and tests.  The nurse and doctor spoke to each other but not to my friend.  They did not ask her how she was feeling, or what she knew about the/her condition, and they did not check the online record for evidence of past evaluations or recommendations.

My friend refused, for various reasons, not the least of which was that this condition had already been thoroughly evaluated, multiple times, and was actually well controlled.  But the doctor and nurse showed no interest in knowing my friend, nor did they seem to care to include her in any medical decision they made about (for) her.

Granted, this is my friend’s side of the story.  But for right now this is where I focus, because her experience is all too common, and I hate it.  She experienced everything that makes physicians and our healthcare system look and feel so broken, and that contributes to the widening relationship gap between patients and physicians/providers.

She was asked to bring her records, she put forth the effort to do so, and they were not reviewed.

She felt ignored and dismissed, even though the objective of the visit was to establish care and initiate a long term, collaborative relationship with a new primary care doctor.

She was ordered to submit to an ambulance transfer to a hospital emergency department, with neither discussion nor negotiation of other care options, and without regard to the financial and other costs to her.

She felt harassed by the office in the following days, receiving calls admonishing her for not presenting herself to the emergency department.

The bottom line is that my friend felt completely unseen in this encounter.  She felt treated like an object—a set of data, a statistic, a box on a flowchart.  Context, history, and individuality be damned.  When you’re in a relationship with someone who is supposed to help you, on whom you rely to help you understand the best plan of care for you personally, feeling unseen, dismissed, and belittled is exactly the opposite of helpful.

Maybe we should not judge the nurse and doctor too harshly.  We all know the time and volume pressures primary care providers live under these days.  Maybe they were distracted by other, sicker patients they had seen that day.  Maybe that made them more vigilant and aggressive with care recommendations for her, and put them behind schedule so they felt they could not take the time to explain things in more detail.  Maybe the doctor had seen this arrhythmia once before, treated it more casually, and the patient died.  We have no idea.  And it matters, insofar as it impacted how he presented to my friend.  Because his presence was dominating, authoritarian, rigid, and cold.

The patient-physician relationship serves as the foundation for medical care and healing.  No matter how much we talk about and try to honor patient autonomy, the power differential in this relationship remains fixed and real.  The doctor has the power and the responsibility to make the patient feel safe, to earn the patient’s trust.  On this day, in this visit, this doctor blew it, in my opinion.  It was their first encounter.  He should have taken the time and interest to get to know her, even a little, to agree on how they would work together.  If he were truly concerned about her health, knowing she had an arrhythmia (which are often made worse with stress), might he not have noticed the distress he was causing her?  Couldn’t he have given her additional care options, like referring her to a specialist within the week?  Or perhaps he could have opened the electronic health record and looked at her previous cardiologist’s last note?

He did none of these things—or at least not in any way that my friend perceived.

Further, he not only failed to establish a good relationship with her; he undermined her trust in our whole medical system.  How many experiences like this does a person have before she starts to reject the medical community altogether, ignoring symptoms of disease because she would rather deal with pain and disability than try to navigate a hostile system?  Fewer than you might think.  This is how patients end up in emergency rooms with truly life-threatening illness, where, guess what?  They get shamed again for not seeking help sooner.

It’s rather tragic when you think about it.

There is hope, though.  But as this post has already a thousand words, my thoughts on solutions will have to wait.

I hope you all had a restful and joyous holiday season.  My unplanned holiday writing hiatus lasted longer than I intended, and it’s nice to be back.  May we all reconnect with one another in more meaningful, productive, and uplifting ways in 2019.

 

 

How Do You Stay Healthy While Traveling?

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Once again Nate Green stimulates my thinking and connects my professional and personal dots.  Last week he asked newsletter subscribers this question, and I was surprised at the cascade of subsequent questions it triggered for me:

How do we define “healthy?”

What about travel threatens and/or challenges health?

Is it different depending on the person?  The trip?

What about the trip—Destination?  Duration?  Time of year?  Companions?  Purpose?

How, specifically, is travel different from home?

How do we apply the answers to these questions?

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In my practice, the patients I see travel, I estimate, an average of 35% of the time.  They endure interstate commutes between work headquarters and home, or fly between company sites and all over to meet customers across the country and around the world.  Inevitably these trips include hours sitting in meetings and then the requisite business dinners.  Such meals present the quadruple threat for acid reflux, among other problems:  They are large volume, fatty, and alcohol-laden, and often occur shortly before people go to bed.  Many patients report that they feel badly after business dinners—bloated, sedate, and a little guilty, or at least concerned, about their health.  They feel little agency to change the pattern—fascinating.  We cannot underestimate the business culture of peer pressure that perpetuates our worst habits of self-sabotage, and I see this as the primary threat to my patients’ health when they travel.  Other challenges include jet lag, poor access to healthy food, and disruption of routine, most importantly sleep and exercise.

I have only started to ask my patients Nate’s question.  One patient knew his answer without hesitation: Do not eat late.  I’m curious to see how others answer, and how their answers may evolve over time.  Perhaps I will add this to my standard questions, after my stress/meaning ratio markers.

Nate’s question invites me to consider for myself, as I prepare to travel for the holidays.

How will I define health on this trip?  I will be healthy if I stay active, protect my sleep, and connect with my people.  I will practice intention and mindfulness.  I will read that which enriches my knowledge, awareness, and relationships, and do my best to avoid click bait, sensationalism, and meaninglessness.

What about this travel threatens or challenges my health?  OMG the food.  It’s not just business dinners that are full of fat, sugar, and portions to satiate hippopotami.  Holiday desserts are my crack—one of these days I might just overdose…  I also tend to stay up too late, usually watching movies, and then sleep in and feel guilty for wasting half a day already.  That kills my motivation to do anything very active, much less a full workout—the day is practically over—what’s the point?  Might as well eat, is there any cheesecake left?

Is this different for me compared to others?  Oh, yes.  My husband seems to have no problem controlling his eating, sleeping, and activity anywhere he goes.  Jerk.

Is travel home for the holidays different from, say, conference travel?  Yes.  I think I am more disciplined at meetings.  There isn’t food everywhere whenever I want it, and medical conferences usually offer more healthy options anyway.  I still stay up too late, though.

So what’s the answer?  How will I keep myself healthy this holiday travel season?

Nate included a video by Matt D’Avella in his newsletter, which made some useful suggestions.  Carve out time at the beginning of each day to exercise.  Get outside if possible.  Make the objective maintenance of fitness and routine, rather than progress—slow and steady prevents injury.   I can probably mark time to do some kind of exercise, just not in the mornings—I hate mornings.

Nate suggests making one consistent meal every day of the trip.  Matt made chicken, black bean, egg, and rice burritos every morning in Sydney.  That fueled his morning workouts, simplified food decision making by one meal a day, and allowed him to explore new foods the rest of each day.  I can probably make breakfast my stable meal each day on vacation.  My morning meal has been haphazard the past few months at home, too, so this could be a great opportunity to regain a routine even after vacation.

JAX gym view

Perhaps my central strategy this time can be labelled “Planning for Real Life.”  Whenever I go home I make grand plans to see everybody, cook a ton, hike, shop, relax, read, write, and organize.  For some reason I always leave feeling disappointed that I could not fit it all in, go figure.  There will be multiple families together this year, lots of little kids.  It’s December, and weather can be neither controlled nor fully predicted.  We can make plans, but kids get tired and lose interest, and adults can have meltdowns of our own.  I can look at the calendar and compare it to my task list for the week.  What do I really need to accomplish?  What did I just write here?  Sleep, move my body every day, read a little, and spend quality time with my peeps.  In other words:  Rest, Train, Learn, and Connect.

Thanks for the prompt, Nate!  And Happy Holidays to you!

Talking to the Opposed About Vaccines

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NaBloPoMo 2018: What I’m Learning

Go figure, I’m having conversations about flu and vaccines every day right now.  Today I described my post from yesterday to a new friend.  He stands firmly in the ‘vaccines are good’ camp.  His sister, however, does not.  Her son has autism.  After hearing about my post, he asked me what I would say to her, if she told me she would not vaccinate her child ever again.  It was a great opportunity to think and practice, and I’m grateful that he asked.  I had already thought earlier today about writing a separate post on communication around vaccines.  So here goes!

First I would tell her that I understand why she would not want to vaccinate, if she blames vaccines for her son’s autism.  I don’t know any kids with autism, but I have friends whose kids are autistic, and I see how stressful and exhausting it can be.  As a mom of kids with anaphylactic food allergies, I also know the feeling of absolute guilt for being the one who gave my kids the things that made them sick.  If I were a mom whose kid was diagnosed with autism after receiving vaccines that I consented to, and I were convinced that the latter caused the former, I would definitely want to protect my kid from anything else that might hurt him, especially anything that I have control over.

Some additional background:  We are a lot better at recognizing and diagnosing autism spectrum conditions now than a few decades ago.  That diagnosis is commonly made in the toddler years, also around the time kids have received a boatload of vaccines.  So it’s easy to see a correlation, but causation cannot be proven.  One could argue that it also cannot be totally disproven, but given the number of children who receive all of their vaccines and the very small proportion of them all who go on to be diagnosed, the evidence definitely leans away from vaccines causing autism.  That is little comfort for a family and a child affected with the disorder, who may always wonder.  As humans, we naturally look to assign blame; vaccines are an easy target.  And why on earth would we repeat actions that have previously caused us trauma, real or perceived?

This year I read an article about a mom of three.   She had vaccinated her two elder children as per guidelines.  After her third was born, however, she started to read lay literature online stoking fear of vaccines.  She had no negative experiences herself, but started to wonder, what was really the best thing to do for her family?  She decided to stop vaccinating when her son was 6 months old.  At 18 months, he got pertussis, or whooping cough.  He almost died.  She posted videos of him coughing and turning blue, captioned with a heartfelt mea culpa, urging other parents to vaccinate:

“This is whooping cough,” she wrote. “This is Brody. An 18-month-old boy. Our third child. Our first son.

“This is a mother that sees ‘anti-vaxx’ all over social media and becomes terrified. Unsure whether or not to give vaccines (even though she did for both of her girls). Terrified to ‘pump her baby with poison’ … so she stops vaccinating after six months.”

“This is pure hell. This is guilt. Guilt of putting not only my son at risk, but my community too …This is embarrassment.”

She wanted to impress the fact that she’s not “bashing” the anti-vaxx community – or blaming or judging anyone.

“The decisions I made were MY decisions. Based purely on my lack of knowledge and fear,” she said.

“This is to show the consequences of not vaccinating my child correctly.”

I wonder about her conversations with her son’s doctors.  Did they try to shame her into vaccinating when she initially expressed a desire to stop?  If so, could this have just made her more resistant?  It could easily look something like a conversation that I would bet happened all over our country today:

Doctor:  Have you gotten your flu vaccine yet?

Patient: I don’t do flu vaccine.

Doctor: Seriously?  Why not?  It’s perfectly safe, you know, and tens of thousands of people die every year from flu.  If you don’t get vaccinated, you could pass it on to everybody you know.  Aren’t your parents elderly?  Don’t your kids have asthma?  You’re putting them at risk for serious illness or death, you know that, right?  And you don’t get flu from the vaccine, that is a total myth.  (Insert list of facts and evidence for benefits of flu vaccine here.)  Really, you should get it (suppressing eye roll).

Patient:  No, no thanks.  Can I go now?

I see and hear my colleagues complain all the time about vaccine-resistant patients.  When they are particularly tired or moody, they can get judgmental and even a little mean.  I understand.  It’s frustrating to watch people we care about making choices we think are against their best interests, especially when it also puts the community at risk.  I fear for my kids if their classmates are not vaccinated—both of my kids have asthma that’s triggered by respiratory infections.  Even if our whole family is vaccinated, they are still exposed to hundreds of snotty, sneezy, coughing faces every day at school.  Flu season is essentially six months long, most of it when we are all stuck inside basically slobbering all over one another.  High. Risk.

But does it really help for me to come at my patients with my ‘advice’ before I understand the origins of their decisions?  What are my assumptions about them when I do that?  Some patients claim science as the basis of their refusal; others admit that it’s totally irrational.  Regardless, how can I best conduct myself?  Here is my current approach:

Cheng: Do you do flu vaccine?

Patient: No, not really.

Cheng: Can we talk about that?

Patient: Do we have to?

Cheng: I would really appreciate it.  I won’t try to pressure you, I just want to understand your rationale.

Patient:  Gives their reasoning.  If it’s like my friend’s sister above, or I otherwise understand that they are resolute in opposition, I thank them for sharing, shift to strategies for illness and transmission prevention (see yesterday’s post), and ask permission to talk again next season.  This happens in a minority of cases, actually.  Most often they say something like, “Well, I just don’t really think about it, I feel like I don’t need it, I think it’s strange that it’s recommended every year, it doesn’t really seem to work from what I hear, and what’s the big deal about flu, anyway? …Do you really think I should get it?”

Cheng: Yes, I really recommend it.  Can I tell you why?

Patient: Okay, sure.

This is when I go through all the evidence that I reviewed yesterday and the rationale above.  If I know something meaningful to them that relates, I make sure to highlight the connection.  At the end I make sure to reiterate that they are free to vaccinate or not; I am honestly unwedded to a particular decision. I invite them to consider and let me know, or just show up to a pharmacy clinic if they decide to get it.  Most people are appreciative of the time spent; many say they learn something they did not previously know.  We end the conversation at least with no hard feelings, and often with positive ones (at least on my end).

It occurred to me this morning, what is my primary objective when I conduct these conversations this way, coming alongside my patients rather than coming at them?  Initially I thought it was to keep people healthy, to prevent death, serious illness, and suffering.  But now I think my primary objective is actually to cultivate our relationship.  I usually have this conversation with new patients, because if I know them already then I know their vaccine patterns and I don’t have to ask, “Do you do flu vaccine?”  If they refused last year I can simply start with, “Can we please talk about flu again?”  When we are new to each other, the way I present sets the tone for our relationship and has an outsize impact on patients’ receptivity to my advice.  The flu vaccine conversation is a prime opportunity to prove that I can listen to, empathize with, respect, and honor their values and autonomy.

On the contrary, when I come at them, bent on convincing them to vaccinate now, what is my primary objective?  Thinking of other times I present this way, if I’m being honest, I’m just trying to prove I’m right and win an argument.  I don’t think that approach has ever really helped anybody.

 

 

What Doesn’t Kill Me

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NaBloPoMo 2018:  What I’m Learning

What does your doctor tell you about flu vaccine?  What about shingles vaccine?  Antibiotics?  This week I have had a series of both unifying and gratifying conversations around these topics.  I thank my patients for sharing their opinions and questions, which stimulate and sharpen my thoughts and expressions, all in service of making us healthier.

People have a lot of reasons for declining flu vaccine.  It’s usually something around not believing it does any good (it does), feeling they don’t need it and are not at risk for serious illness or death (we all are), and a general aversion to ‘putting something in my body that isn’t natural.’   Most people who decline flu vaccine still accept tetanus/diphtheria/pertussis, hepatitis, meningitis, or other vaccines.  I find this interesting.  The rationale behind all vaccines is the same—saving lives and minimizing serious illness and complications, especially for vulnerable populations like babies, the elderly, and people with immune-compromising conditions (pregnancy, cancer, diabetes, autoimmune disorders).  We are contagious before we feel sick—this is the natural genius of viral survival and spread.  So this flu season, cover your face with your arm when you sneeze, wash or sanitize your hands after every encounter with any surface, and don’t share drinks or utensils with anybody.

Shingles is interesting.  You cannot get shingles unless you have had chicken pox or the chicken pox (varicella zoster) vaccine (though shingles after vaccination is rare).  After the acute illness (and sometimes after vaccination), the virus does not go away.  Like other herpes viruses, it lives in your body permanently and reactivates under certain conditions.  In my experience the most common trigger for shingles (zoster) is stress, either physical (eg sleep deprivation) or mental and/or emotional—often both.  The virus resides in the spinal cord and reactivates usually along a single nerve root, hence the typical pattern of a band of blisters on one side of the body.  For someone who has not had chicken pox or the vaccine, infection occurs through contact with respiratory droplets from someone with either chicken pox or shingles illness.

Here is my best analogy for how vaccines work:

Think of your immune system as law enforcement or a military operation.  Its job is to hunt down offending agents, apprehend them, subdue them, and kill them, if possible.  All such operatives need training to be effective.  Vaccines are like battle simulators.  We deploy them into circulation and trigger a drill response from immune system troops, making mobilization for the real, live attack more efficient and successful.  In the case of flu, offenders are shapeshifters, constantly changing their outward appearance to evade capture.  So simulators must be updated annually to prepare the troops in kind.

For shingles, think of varicella zoster virus (VZV) as the prisoner, your spinal cord as the prison, and your immune system as the prison guards.  Usually VZV breaks and enters when we are young, when our guards are also young, fit, and agile.  Over the years, our guards age.  With age comes sluggishness, memory loss.  The prisoner, however, remains as virulent as ever.  So it looks to escape through one window or another—maybe a left thoracic nerve root this time, a right lumbar next.  Shingles vaccine takes our dad-bod prison guards back to boot camp and reminds them what the enemy looks and acts like, so they may better thwart any escape attempts.  The new shingles vaccine, Shingrix, is recommended at age 50.

So, vaccines are basic training for our immune system soldiers.  I’ve never been anywhere near the military (God bless all of you who serve, and does residency count for something?).  For those who have, do you agree that there may have been times during training when you questioned your likelihood of survival?  And when you did survive, did you not emerge stronger and more confident for the experience?  What doesn’t kill me…

It’s the same for bacteria exposed to antibiotics.  There is no question, we use antibiotics too much.  Now think of bacteria as a horde of enemy invaders.  Our immune military wages war with these throngs at every orifice and mucus membrane of our bodies every day.  Every time we take antibiotics, however, it’s like coming over the battlefield with an imprecise explosive device aimed at the bad bacteria, but that also can cause collateral damage (eg friendly fire on our good gut bugs).  The problem with antibiotic overuse (and, in theory, shortened or incomplete courses of antibiotics) is that the bacteria who were already equipped to survive the blast now make up the majority of the surviving invasion party who can procreate.  They will pass on these survival traits to their progeny, and voila, antibiotic resistance.  The next time you have a respiratory infection, do not automatically assume you need antibiotics.  Talk to and/or see your doctor.  If it’s an uncomplicated viral illness, ask what else you can do to suffer less while your troops battle this transient, non-lethal invader.  Support them by hydrating, sleeping, eating healthy, and avoiding caffeine and alcohol.  Support yourself by medicating for the symptoms.  You’ got this.

What does not kill me makes me stronger.

It works both ways.

Living Large in Seventh Grade

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NaBloPoMo 2018: What I’m Learning

Did you know that Abraham Maslow never represented his hierarchy of needs as a pyramid?  I didn’t either!  To be clear, I have not read the paper I just linked; it was linked in a different article I read today, describing more about Maslow’s work than I have ever known before.  It’s in Scientific American, entitled, “What Does It Mean to be Self-Actualized in the 21st Century?” by Scott Barry Kaufman.

Especially later in his life, Maslow’s focus was much more on the paradoxical connections between self-actualization and self-transcendence, and the distinction between defense vs. growth motivation. Maslow’s emphasis was less on a rigid hierarchy of needs, and more on the notion that self-actualized people are motivated by health, growth, wholeness, integration, humanitarian purpose, and the “real problems of life.”

I was intrigued by this piece because I remember so clearly when I first learned about Maslow’s Hierarchy.  It was in seventh grade, and I can’t remember anymore the class or context.  I just recall that it made so much sense, and I felt such a swell of joy at the possibility that something so complex could be distilled and explained so simply.  It would have been fair to predict at that time that I would go on to become a psychologist.  The boy I had a crush on that year (and all through high school, actually) asked me where I saw myself on the pyramid.  I remember looking at the tiers and thinking, very clearly, oh, I’m at the top.  I felt a little sheepish, afraid I would be seen as bragging, but it was the honest answer, and I said so.  “Bullshit,” was his reply.  I can’t remember our verbal exchange thereafter, but I think I was able to convince him that I really felt like I was ‘there.’  And I left that encounter feeling both a bit more self-aware and also proud that I had stood my ground and defended a truth.  You could also have guessed I would later entertain a brief interest in law school.

Kaufman has revisited Maslow’s work, including his hierarchy of needs, and evaluated the components in the context of modern life.  Reassuringly, 10 of 17 of Maslow’s self-actualization characteristics still stand up to ‘scientific scrutiny,’ (not sure how he measured this).  He names the ten characteristics in the article, and you can ‘take the quiz’ to see how self-actualized you are today.  I love quizzes like this.  I have done the Myers-Briggs at least 5 times.  Others I love are Gregorc Mind Styles, Insights Discovery, and the Gallup Strengths Finder.  The most useful ones tell you what you already know about your strengths, and also offer advice and insights on how to manage your blind spots.

But the most interesting aspect of Kaufman’s article to me was Maslow’s interest in self-actualization and its relationship to self-transcendence.  We can understand self-actualization as ‘achieving one’s full potential’ and self-transcendence as ‘decreased self-salience and increased feelings of connectedness,’ (again, not read the paper; it’s linked in Kaufman’s article) or basically subsuming and/or integrating oneself within a greater whole.  At first you may think that these are mutually exclusive states of mind and being.  The coolest thing is that it’s not actually an either/or proposition; it is absolutely both/and:

While self-actualization showed zero relationship to decreased self-salience, self-actualization did show a strong positive correlation with increased feelings of oneness with the world.

Self-actualized people don’t sacrifice their potentialities in the service of others; rather, they use their full powers in the service of others (important distinction). You don’t have to choose either self-actualization or self-transcendence– the combination of both is essential to living a full and meaningful existence.

It reminds me of another subsection of Chapter 3 in Leading Change in Healthcare, wherein Suchman et al discuss holding the tension and balance between self-differentiation (clear sense of individuality) and attunement (deep awareness and acceptance of how we are connected and resonant with those around us).  It also reminds me of Brené Brown’s work on trust; she describes eloquently in Rising Strong how we can neither trust others nor be trustworthy ourselves without clarity and boundaries around who we are and our core values, and living in that integrity all of the time.

Once again, I find encouraging and validating evidence for something I really feel I have known since an early age:  We are all our best selves and our best communities not in competition, but in collaboration.   Cohesion in diversity weaves a stronger social fabric of connections, more flexible and elastic.  But that means we need to know exactly what we as individuals each bring to contribute.  Personal, intrinsic meaning and purpose are foundational for substantive interactions with others and resilient communal relationships.

Our world can meet each and every one of our physiologic, psychologic, and self-fulfillment needs—we can provide this for one another.  We can each strive for our own goals, alongside our peers, and still help each other on the rocky, uphill parts.  We really need to stop with the scarcity thinking and get on with the business of working together, maximizing each of our strengths, and making society better for all of us.

Onward.