Finding Peace in the Morass

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Friends, how are you feeling and doing today?

Three weeks ago workouts and bedtime went to hell for me, as it became clear that coronavirus would soon turn our lives upside down and inside out.  I could not read fast or widely enough.  At the end of that week I posted three times in four days, discharging all that I was learning, attempting to convince anybody I could that the tidal wave was coming.  I felt like Chicken Little.

The last two weeks saw myriad conference calls, reorganizations, virtual team huddles, sleepless nights, workflow changes, text threads, mood swings, mass emails, sporadic workouts, and also moments of connection, both personal and professional.  In an effort to stay informed, I put Facebook back on my phone, to keep up with the medical COVID groups sharing information and experience.  It’s exhausting.  As of this moment that app is once again deleted.  I need a better new normal.

I’m not doing my usual in-depth, in person interviews and exams with patients.  I really miss it.  But my phone conversations have been no less meaningful.  I hear about my patients’ cough, fatigue, fevers, headaches, and sore throats.  Some have diarrhea.  Some can get tested for coronavirus, others cannot.  We work through it day by day.  I also hear anxiety, confusion, frustration, fear, and uncertainty.  I do my best to be objective and evidence-based, as well as compassionate and empathetic.  I always wish I could do more.

I think it’s uncertainty that people fear the most.  When we don’t know what will happen, especially when the possibilities are as divergent as COVID-19 outcomes, everything is nebulous and scary.  What can we expect?  How should we prepare?  If we choose one path, what if it turns out differently, and we did the wrong thing?  How will we cope?  All this social distancing and sheltering in place—it’s decimating the economy.  Those voicing concern over this must not be dismissed.  Meanwhile, what do we do?

If I feel sick, am I infected or not?  Am I contagious or not?  I can’t get a test.  What should I do?

*****

Over the holidays I read Being Mortal by Atul Gawande, my favorite physician writer.  His eloquent and accessible writing on aging, illness, and the American end of life experience should be required reading for every physician, and really every adult.   After finishing the book, I decided that in order to die at peace, we must live in peace.  And peace must be cultivated.  It’s not something you can invoke in the midst of crisis, unless you have practiced.

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Let Your Breath Lead You

I learned about box breathing at the International Conference on Physician Health in 2016.  It resonated because I had already attempted a mindfulness meditation practice for some years, with varying success.  Inhale, hold, exhale, and rest, each for a count of four.  This is not a normal breathing pattern.  So it’s both a mental (attention) and a physical (parasympathetic stimulus) practice.  It lowers blood pressure and heart rate, and eventually cortisol levels.  It is also known as tactical breathing, as soldiers train for combat with this very practice.  The objective is focus and calm at the same time.  I have practiced since 2016, also with varying consistency and success.  These three weeks I have pulled on this technique as a matter of course, and it has saved me.  When the mind is full and chaotic, we can call on the body to lead us to peace.

Accept and Embrace Paradox

Human nature is to overgeneralize and oversimplify.  We seek simple, compartmentalized solutions to complex problems, often in binary form:  black or white, open or closed, good or bad.  But much of life is simply the opposite of simple (ha!), especially during a pandemic of a novel virus.  What we need is a way to tolerate the inherent ambiguity and uncertainty that life will always bring.  Here I must credit “The Big Bang Theory” for teaching me about Schroedinger’s Cat.  It’s a physics thought experiment in which a cat inside a box with a toxic radioactive substance can be thought of as, paradoxically, simultaneously alive and dead until the box is opened and its true state revealed.  In the case of coronavirus:  If you have had an exposure and you feel fine, or if you feel sick but it’s not that bad, and you cannot be tested, your true state is either infected or not infected.  But since we cannot know, we can consider you to be both.  So what should you do?

  1. Be grateful that you are not gravely ill.
  2. Act like you’re healthy, and live your life.
  3. Act like you’re infected, and don’t do things that will infect others.
  4. Practice, with deep, box-like breaths, the skill of accepting and embracing paradox.

Make a Choice

Even as I advocate vociferously for people to stay home, I understand the economic consequences of this intervention.  Rock, meet hard place.  For a while I asked myself  which I would regret more:  Executing defensible drastic measures in response to those who warned us for months, and then having it be ‘not that bad’ (because we all already know it will be some version of BAD), or doing less than was recommended and having it be unfathomably bad, like it has been in Italy, and what New York City already is?  Lives will be ruined either way, and deaths will escalate, directly from the virus and indirectly from all kinds of other things.  But I could not live in good conscience if we knowingly chose the latter path; I personally would regret that more, and I think our leaders and my profession would be crucified.  Because there are very few ways to prevent the direct deaths now—we missed the boat of containment.  Now our only hope is to slow the spread so as not to overwhelm our hospitals.  But there are myriad options to prevent and mitigate the indirect suffering and death, economic and otherwise.  That is where we can still exercise agency, creativity, collaboration, and innovation.

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Nobody knows what lies on the other side of this morass.  Life will never be like it was before—but that has always been the case.  Make no mistake though: we are all in it together, like it or not, know it or not, want it or not.  At no other time have we seen more clearly how the actions of one affect the outcomes of the many.  In another example of paradox, each of us is both victim and agent at the same time.

So how can we achieve peace?  Look for the helpers, as Mr. Rogers’s mom advised.  Be a helper, as much as you can.  Breathe through the anxiety; connect with those who help you.  Let go false dichotomies and breathe some more.  Plan and execute your small and significant contribution to maintaining and rebuilding the economy.

And please, please—for now—stay home.

 

Standing By

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UGH. The tsunami is coming, my friends. The alarms have sounded for so long already.

And we KNOW what to do!  We can brace the shore for it and decrease loss of life.

I just spent all weekend working on operations reorg and mobilization–so proud of the teams who worked around the clock to prepare for the worst.  While we wind down non-essential practice functions, we ramp up in crisis mode.  We will redistribute clinical staff to where they are most needed.

But we need EVERYBODY to pitch in and help out.

Please please please do your part.  LEAD BY EXAMPLE.

I’m already wondering which of my friends will get sick. So many people I admire, dedicated professionals and teachers, people who make the world better, work in our emergency departments and on the hospital floors. They care for the sickest of the sick.

Please do your part to NOT put them in harm’s way.

I am a vector. You are a vector. We are all vectors. That is why we need to keep physically separate right now.

This kind of separation is temporary.

Let us tolerate it and help minimize the kind of separation that is permanent.

***

From Jennifer Leung, MD:
Takeaways from the UCSF COVID-19 town hall [this week]:

1. If you’re exposed to COVID, you’re likely to see symptoms in about 2-9 days, with median of 5 days.

2. The common symptoms are acute respiratory distress and fever, often high, which may be intermittent but can be persistent and last over 10 days.

3. Breakdown of cases: About 80% of those who contract COVID only get mildly ill; 14% get hospital-ill, 6-8% critically ill. The mortality rate seems to be between 1-3%, but that needs to be adjusted for age. Mortality is 10-15% over 80, and drops lower for younger cohorts.

4. The bulk of those who fall ill are aged 40-55, with 50 being the median. But being young and healthy (zero medical problems) does NOT rule out serious illness or death; it may just delay the time course to developing significant respiratory illness by about a week or longer.

5. Findings [suggest] that COVID-19 is spread simply through breathing, even without coughing [edit 3/17: I am still looking for primary source evidence for this; one experimental/model study showed the virus staying aerosolized for three hours; it is unclear what this means in real life]. It seems unlikely that contact with contaminated surfaces is a primary means of spread: “Don’t forget about hand washing, but if you don’t want to get infected, you can’t be in crowds.”

6. The virus spreads by air and in droplets (sneezing and coughing), but also via fecal-oral transmission. This is where hand washing with soap is key. And try to eat only cooked foods if you didn’t prepare them yourself.

7. COVID likely originated in bats. But for those sharing rumors that COVID came from Chinese people eating them, researchers now believe it went from bats to another animal species before jumping to humans, and that fecal-oral transmission was the likely vector. WASH YOUR HANDS.

8. There are no real treatments for COVID yet. Remdesivir has shown signs of reducing mortality but it is still in tests, is in short supply and only available under restriction. Steroids, a common treatment for respiratory illness, may make things worse.

9. The terminal phase of COVID is acute respiratory distress, treated by putting patients on a ventilator. We have 160K ventilators in the US. About 1M will need ventilators. Half will die in the first week; survivors stay on for 4 weeks. “We don’t have enough ventilators.”

10. …Italy is already overwhelmed. Many countries are just days behind Italy on the case curve. The US is actually breaking the curve–[due to severely limited availability of widespread testing].

11. 40-70% of the US is likely to get the virus. Around 150 million is the UCSF estimate, with a 1% rate of mortality. Which means 1.5 million Americans will likely die of this disease in the next 12-18 months.
To put this in context: In 2019, 606,880 Americans died of cancer.

12. We are “past containment” at this point, experts say. The [lack of early unified intervention made] it impossible to stop the spread—we can only slow it so healthcare can catch up. And no matter what anyone says: We won’t have a vaccine for at least 12 months.

Sexism and Apologies 2020

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“If you say, ‘Yeah, there was sexism in this race,’ everyone says, ‘Whiner!’ If you say, ‘No, there was no sexism, about a bazillion women think, ‘What planet do you live on?’”

That is how Senator Elizabeth Warren answered a reporter when asked whether she thought gender played a role in her suspending her presidential campaign.  I recommend watching the whole video clip.  In case anyone wonders: if the question even needs to be asked, then yes, gender played a role.  But Senator Warren rightly called out the question for what it is: a trap for any woman running for high elected office.  Her statement summarizes it succinctly; she knows what’s what, and she names it without apology.

I was more upset than I expected when Aunt Eliz Crusader ended her campaign.   Megan Garber expressed the story of my profound disappointment eloquently in her piece for The Atlantic:  “America Punished Elizabeth Warren for her Competence”.  Basically she elaborates the apparently inevitable social equation for women:

Competent  +  Vocal  +  Unapologetic   =   “Strident”  +  “Shrill” +  “Condescending”

The past two weeks I have had a series of encounters wherein I find myself voicing opinions and positions more firmly than I might have in the past.  I feel confident and grounded in my knowledge and expertise.  I am professional and respectful.  I apologized for writing a long email, even though the words were necessary and clear.  My strong woman mentor reminded me to save apologies for when I actually commit a transgression.

What I have learned (perhaps again) in this time, however, is that relationship discord, even just the possibility of it, is what distresses me the most.  How will I be perceived for voicing my concerns, for advocating for my peers and teams?  How will a negative perception undermine my effectiveness?  Will it cost me my seat at this table or others?

Does any man ask himself these questions?

Given that I was already knee deep in vulnerability and self-doubt around these encounters, the Atlantic piece poked my fears and prodded them to the surface.  It shook me.  It also made me angry that here we still are, in 2020, unable to accept, let alone embrace, competent, vocal, and unapologetic women in leadership.  And it’s not just men; countless women also disavow their sisters.

I vented my disappointment on Facebook (of course):

“So it is down to three Old White Men.  Very disappointing.”

A friend tried to make light of the situation, pointing out that Donald Trump is the youngest of the three.  This attempt at levity (from the Right) felt like a nemesis rubbing salt in my fresh wound.  Twice I rebuffed; twice he persisted.  Finally I (voiced):  “I feel ignored and dismissed when I express distress and you make light of it.  Perhaps my distress is not clear to you, because you only know me through social media [we were friendly acquaintances in high school]; you may not know how upset I am.  But after two replies by me rejecting your attempt at humor, to have you schooling me [that humor is a ‘primary’ way] of dealing with [politics] just makes me more angry.”

Turns out he had mistyped; he’d meant to write that humor is one of his primary ways of coping with the absurdity of politics.  He apologized to me.  It felt sincere.  I was consoled, and I thanked him.

Competent and vocal.  Confident and unapologetic.  Respectful and humble.

We need all of these qualities and more to be true leaders.  Women, arguably, must work harder than our male counterparts to prove that we possess all of them.  Then we get punished when the proof proves irrefutable.  How sadly ironic.  The truth is we need many more of our leaders, men and women alike, to own, exude, and model these virtues.  The last two are not weak, though they may feel profoundly vulnerable, which is not the same thing.

I feel urgent impatience at the state of sexism in America.  But I know how to soothe and manage myself; I can reclaim the patient urgency of fierce optimism at my core.

I will persist.

Aunt Eliz has shown me how.

Caring for One Another

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Last Saturday a patient cared about me.

He had severe abdominal pain that had kept him up all night and he needed advice.  By the time we agreed on a plan he had apologized, at least three times, for ‘bugging’ me on the weekend.

I explained that it’s okay to ask for help on weekends. I’m happy to help if I can, and the relationship is the most meaningful part of my work.  I also thanked him for not abusing that relationship—for not taking me for granted, for seeing me not as a transactional service provider, but as a person with a life outside of work.

When we feel seen and appreciated, life is easier to take and we function better.

* * * * *

Recently I’m thinking about organizational values and mission statements.

For the most part I find them superficial and unhelpful, wordy and convoluted.

As I consider the team I have led the past two years, I feel proud that although we have not formally written mission or values statements, we are nonetheless clear on both.  We define them in succinct language, gauge how we manifest them through action, and reconcile behaviors, conflicts, and initiatives against them regularly.

Our values, collectively adopted one year ago:

  1. Fun, joy, creativity
  2. Collaboration and Connection
  3. Accountability
  4. Kindness and Compassion

Reviewing the list, I see that caring for one another serves as the foundation for this house.  This applies both to the team’s inner work, as well as anything facing outward toward patients.

It is of course our responsibility as professional caregivers to manage ourselves and show up our best for our patients.  I expect patients to treat our team with respect, but we should not necessarily feel entitled to their caring about us, per se.  It is our job to care for them; the relationship is inherently imbalanced in that way.  In order to do that well, we the team must also care for and support one another in service of our vocation.

So every once in a while, when a patient expresses genuine caring for me or a member of the team, in addition to appreciation for a job well done, it really brightens our day.  It keeps us going.  It makes all the unappreciative, and even abusive, encounters worth it.

Thus, we march on.  We remember why we do this work and we hold each other up.

* * * * *

Please know how much your expressions of affirmation matter to your medical team.

We’re all here caring for each other in this life.  The more we can remember that and act on it, the better off we will all be, no?

What Makes You a Leader?

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Is it your title?  Your reputation?
Is it your status?  Your paycheck?

“If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

This quote is attributed to John Quincy Adams, but there is apparently no evidence that he actually said it.  Dolly Parton, on the other hand, said,

“If your actions create a legacy that inspires others to dream more, learn more, do more and become more, then, you are an excellent leader.”

Your actions make you a leader.
Anybody can lead, as long as people are willing to follow.
So what makes people follow?

I think it’s actions grounded in:
Conviction
Authenticity
Openness
Inclusion
Transparency

Accountability
Resonance
Collaboration
Belonging
Integrity
Honesty
Humility
Consistency            …what else?

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So:  How do you lead others?  How aware are you of your leadership, day to day, moment to moment?  How intentional are you about it?
What do you lead others to and for?
What is your purpose in leading?
What is your goal for those you lead?

What is your goal for your cause?

What do you want from your followers?
What do they need from you?
How will you make it so that your cause outlives and continues to flourish without you?

Great leaders do not always know the answers to all of these questions.

But they ask and consider them, regularly, honestly, and humbly.

Attune and Differentiate:  One Week’s Synthesis

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Friends, don’t you just love when an idea you resonate with recurs in your consciousness from disparate sources in short order, further deepening its meaning?  I share three pieces with you this week, which all deepened my commitment to embracing the paradox of attunement and differentiation.

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First, I listened again to Brené Brown’s Braving the Wilderness.  I highly recommend this book to help us all, conservatives and progressives alike, engage (not avoid) one another this election year with a lot more compassion, civility, and mutual respect.  Throughout the book Sister Brené shares personal stories as well as evidence from her research that define true belonging, which I think of as another expression for self-actualization and self-transcendence.  In her words:

True belonging requires us to believe in and belong to ourselves so fully that we can find sacredness in both being a part of something, and standing alone when necessary. But in a culture that’s rife with perfectionism and pleasing, and with the erosion of civility, it’s easy to stay quiet, hide in our ideological bunkers, or fit in rather than show up as our true selves and brave the wilderness of uncertainty and criticism.

Attune and differentiate:  these two practices are not only not mutually exclusive, they are essential and integral for whole person and societal health and well-being.  Read the book to adopt her four practices to advance true belonging, for yourself and for all of us:

  1. People Are Hard to Hate Close Up. Move In.
  2. Speak Truth to Bullshit. Be Civil.
  3. Hold Hands. With Strangers.
  4. Strong Back. Soft Front.  Wild Heart.

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Second, I met Massimo on Ozan’s last Inner Circle Zoom call.  He is a designer and facilitator from Italy—thank you again, Ozan, for connecting so many of us all around the world!  Massimo has launched a blog, which resonated with me because he also advocates finding your voice (differentiating) as well as finding a community of belonging (attunement) as a reason to write:

…Meet new people and to interact with them

Learning adventures can make you feel on a solitary path, too much unbalanced on the input, reading and digesting side without much interaction. Expand your network, look for more interactive exchanges with whom might provide an alternative, critical point of view compared to yours. Exposing your opinions leads self-selecting people to network and resonate with you. Find your tribe. We need many and none at the same time. You need different communities where to manifest and explore your interests. On the other hand, you need to better focus on creating those which are more fertile ground to nurture your continuously changing interests and aspirations.

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Third, I read David Brooks’s article in The New York Times on the ethos of Scandanavian education.  Eloquent as usual, he synthesizes a complex set of ideas into language we can all understand:

19th-century Nordic elites…realized that they were going to have to make lifelong learning a part of the natural fabric of society.

…(Their system) is devised to help (students) understand complex systems and see the relations between things — between self and society, between a community of relationships in a family and a town. 

…Nordic educators also worked hard to develop the student’s internal awareness. That is to say, they helped students see the forces always roiling inside the self — the emotions, cravings, wounds and desires. If you could see those forces and their interplay, as if from the outside, you could be their master and not their slave. 

…Their intuition was that as people grow, they have the ability to go through developmental phases, to see themselves and the world through ever more complex lenses. A young child may blindly obey authority — Mom, Dad, teacher. Then she internalizes and conforms to the norms of the group. Then she learns to create her own norms based on her own values. Then she learns to see herself as a node in a network of selves and thus learns mutuality and holistic thinking. [See Changing on the Job by Jennifer Garvey Berger for more on this theory of adult development.]

Scandanavians…have a distinctive sense of the relationship between personal freedom and communal responsibility.

(Meanwhile, in the United States…) If you have a thin educational system that does not help students see the webs of significance between people, does not even help students see how they see, you’re going to wind up with a society in which people can’t see through each other’s lenses.

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In 2020 more than ever, we need to cultivate much stronger relationship skills.  We must identify and honor our core values and stand up for them, even when attacked by those closest to us—perhaps even especially then.  How we honor our best selves determines how we honor others.  When we show up at our most honest and authentic, we can call forth the same in others to meet us.  We can relate as fellow humans, inextricably connected, mutually interdependent, and all in it together.  Once we realize this, we can know in our hearts that we truly belong to ourselves and to one another, and we can more easily get on with the world’s most important work—connecting humanity in health, safety, and love.

Be a Connecting Node

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How would you describe American political culture today?

What about the culture at your workplace?

In your family?

Are dissenting voices welcomed?  How do those in authority wield their power?  Do the led have a say in decisions and policies that affect them?  Are their needs and interests taken into account by those who lead?

What role do you play in each of these systems?  How do you contribute to the function, dysfunction, morale, and relationships in these interconnected, overlapping, inextricable and sometimes tenuous systems?

How much of these cultures do you own, do you take personal responsibility for?

I have written before about the interaction between a system and its individuals.  In each of the systems I name above—our nation, your workplace, your family—you are a single individual, a node [a point at which lines or pathways intersect or branch; a central or connecting point].  You are connected, directly and indirectly, to every other node in all of your systems.  Thus, you connect each of your overlapping systems to every other one.  So do I.  This is how we are all connected, every single one of us, and our planet.

Thus, what you do affects me, even if I have never met you, even if we live on different continents, in separate generations, speaking mutually unintelligible languages, and vice versa, for all of us.

Octavia Butler said it best:

All that you touch
You Change.
All that you Change
Changes you.
The only lasting truth
Is Change.
God
Is Change.

So how do you change what you touch?

Do you make it better than it was?  Does the change you make make you better in return?

If the only lasting truth is change, then what do we want tomorrow to look like?  What about next year?  What kind of world do we want our grandchildren and their grandchildren to inherit?

Are you a node that connects, using your power and love to thicken the ties between your adjacent nodes and systems, making them stronger and more resilient?  Who is healthier, stronger, and happier for you having touched them?  How have they then extended that health, strength and joy to others?  How have you resisted destructive forces and stood in the way of systems disintegration?  Whom have you protected?  What did it cost you, and what did you gain?  What have you earned?  How will you persist?  What and who hold you up?  On which nodes do you lean, from which do you draw strength, and how then do you pass that strength on?  How do you influence and co-create the culture around you this way?

Or are you a destructive, severing node?  How do you go around blowing up connections, weakening relationship infrastructures?  Maybe you don’t see it this way. Perhaps you see your work as culling, pruning, removing extraneous nodal debris, clearing the path for a more righteous supersystem to rise.  What does this cost you?  Is the benefit worth the price?  Who are your coconspirators in this effort?  How do they change you for your connections to them?  How do you expect your connections to other destructive nodes to evolve?  What is your impact on your systems cultures, being this way?

I suspect we all possess both poles of nodal potential.  Probably most of us go about our days in relative mindlessness, speaking and acting as our surroundings and culture dictate, by convention and custom.  We suppress the inner dissonance that arises when our personal instincts run counter to prevailing winds of rhetoric.  We fear losing connections if our personal nodal identity reflects a different light or sounds a different note from the collective thrum.  The status quo feels easier to uphold.

I posit to you today that our systems are disintegrating fast, eroded by myriad destructive nodes, spreading like slime mold on a global petri dish.  I argue that our collective political culture suffers much today from these destructive nodes, and connector nodes struggle to nurture ties and maintain relationships.  In such times, we may feel tempted to give in, to allow our inner rage monster to tantrum, to succumb to swelling, destructive, disconnecting culture.  Indeed, it is hard to resist.

And yet, we continue.  We march on.

Culture is created and maintained in each day to day interaction between all members of a system. Any individual may choose, at any time, to maintain the status quo or make a shift. It is the accumulation of multiple small shifts, simultaneously and in series, that moves a system to a new, improved state.  Each day we awaken, we have a choice—an infinite series of choices—to make a shift toward connecting and strengthening our intertwined systems.

Do not wait for someone else to go first.  Make the choice yourself, today, right now.  Be a connecting node.  Speak and act, post online, and show up in person, irrefutably, as a connector.  Make your touch productive and generative, inclusive, empowering, and communal.  See how this changes how others show up to you, and how that changes you for the better still.  Then watch the slime mold recede before your eyes as connector node energy amplifies and restores balance.

Slime molds recur.  Connecting nodes hold the line.  We need you.