Love You Into Being

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

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

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

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

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

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

Innocence, Indignation, and Idealism:  An Optimist’s Reconciliation

I took my daughter to see “Wonder Woman” last weekend.  I highly recommend it—such a strong, complex, and inspiring portrayal of humanity at its best and worst, with a hopeful ending.

Today I’m (somewhat) inspired in parallel by (some) politicians, three Republican senators in particular, calling for transparency in drafting healthcare reform.  I hereby present my attempt to integrate that exquisite Wonder Woman Experience with my current political outlook.

***WARNING*** THIS POST MAY CONTAIN SPOILERS FOR THOSE WHO HAVE NOT SEEN THE MOVIE.

Innocence

Diana of Themyscira grows up believing in the innate goodness of humans.  The Amazons are educated, independent, strong, and proud, and also collaborative, compassionate, kind, and sensitive.  When Diana learns of the horrific war waged by mankind outside of her paradise home, she relates it to the story of Ares, the God of War, who corrupts the hearts of men to commit acts of hatred upon one another.  So, naturally, she sets out to kill Ares and fix it.

We journey with Diana through challenge and triumph, as she learns that, of course, it’s not that simple.  She kills the man she thought was Ares, and nothing changes, the war rages on.  She must reconcile the possibility that the heart of mankind is not actually pure goodness.  Even without an insidiously corrupting God of War, humans are prone to their own malignant beliefs and actions.  Her innocence is pierced.

In the summer of 2009 or 2010, my best friend from college and his wife came to visit.  He, a molecular biology and political science double major and emergency medicine physician, and she, a worldly intellectual and future legal counsel for a major media outlet, were the first to burst my innocent political bubble.  For some reason, likely due to the tremendous inspiration of Barack Obama, I had gone from thinking all politicians were liars and performance artists, to seeing them as genuine public servants, working to advance their authentic ideas of how society functions better for all citizens.  I know, La-La Land!  My friends described an alternative, more realistic path to politics: Person succeeds at business, rubs elbows with regulators and influences them (with money or otherwise) to facilitate his/her business success.  Said person then realizes s/he could actually become one of those regulators and make a more permanent positive impact on these business interests, and so runs for office.  I still remember how deflated I felt, shoulders slumped, spine rounded, at this sudden and stark realization.

Indignation

As with everything, I’m sure political reality lies somewhere in the messy middle between pure altruism and blatant, self-serving avarice.  But these days, for someone who loved Obama and almost everything he stood for, it’s hard not to see the whole of our current political landscape as the latter.  I think, Really, WTF?  Can those in power really see nothing valid whatsoever in anything accomplished the past 8 years?  Do they really think that see-saw policy-making, each administration reversing everything from the previous one, replacing wise, experienced public servants with ignorant neophytes (my opinion), is the best way to govern?  OMFG, you have got to be kidding me.  I seethe.  But what can I do?

Ares reveals himself, and taunts Diana in her most vulnerable moment with his arrogant disdain for man’s weakness and corruptibility.  He also reveals that she is, in fact, the only one who can vanquish him—only a god can kill another god.  Diana, daughter of Zeus himself, possesses the power to Kick. His. Ass.  Yet he dismisses her out of hand, oblivious to her inner strength of conviction and compassion (I know, so much to expound on here, maybe in another post!).  Nope.  Righteous indignation rises.  She digs deep, finds that core courage, and obliterates him.  Fist pump.  He never saw it coming.

Idealism

In the end, Diana realizes that humans are a paradox: a big jumble of contradictions, perpetrators of horrific rage and destruction, and also fully worthy of love, forgiveness, and compassion.  She somehow finds peace in this enigma, loving the best of humanity and vowing to protect us against our worst selves, helping us to become better.

This resonates with the idealist in me.  This is how she helps us, and how we can help ourselves.

How Can We Help?

We can choose to fight against one another, and thereby focus on what we hate (about ourselves).

Or, we can choose to seek the good in one another, and focus on what we love— even better, focus on love itself.  We all want access to healthcare, and to be free from bankrupting medical expenses.  Everybody wants to be safe from gun violence.  We all want an efficient government that sets reasonable regulations, protects citizens’ constitutional rights, and spends money wisely and with accountability.  We all want to feel protected and free, loved and free to love.

The messy middle is the how.  That is where we negotiate.  That is also where the magic happens, as Brené Brown says, and that is where we must go, where we must persist.  We can bring our best selves to meet others’ best, in mutual respect.  It can be high risk, so we can enter slowly, strategically, with realistic expectations and a few trusted friends.

To this end, I will continue to seek out and hold up elected officials who call for more thoughtful political processes.  My friend Triffany and I have made a habit of writing thank you notes to Members of Congress to validate their cooperative acts.  We harbor no illusions about purity of intent, but we also know that positive reinforcement works.  We can be Diana to anybody’s Ares.

Focus on and fight for what we love: common goals and interests, shared humanity, connection, and one another.  It’s a lifetime’s worth of work, and well worth the fruits, if we can stick with it.

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Getting Past ‘You Suck’ as Dialogue

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Hello again friends, and Happy New Year!  It feels good to be back.  Diving right in with long form again…

This recent article from Wired got me thinking (again), there are so many layers and moving parts to healthcare reform, that no one player stands to lose all or benefit all from any changes.  And yet so much of what we read and hear has an, ‘it’s so simple, they just don’t care about you, but I do’ tone.  The piece describes why insurance companies, who may have advocated most fervently against implementing ACA regulations, actually have a stake in maintaining its current status.  Nothing in our healthcare system is black or white, all good or all bad.

So when I see politicians (and friends) speaking and writing in oversimplified sound bites, and vilifying a whole group (all liberals, all Republicans) over one aspect of their point of view, it really frustrates me. That is exactly the opposite of productive dialogue.  It just makes people stop listening, because they don’t feel heard or understood.  So they have no incentive to hear or understand you.

Many use the car insurance analogy to explain health insurance.  It’s not exactly parallel, but it makes some sense.  The law requires every car to be insured.  (Drivers of) cars that don’t violate traffic law get lower premiums, the longer they stay ‘safe.’  The more traffic law violations, the higher the risk, the higher the premium.  I have an actuary friend, who works for a health insurance company, who advocates, in part, for higher premiums for those who ‘use’ the healthcare system more—like the higher risk cars (drivers).  I understand this logic.  But this idea of making older and sicker people, and women pay more, just because they ‘use’ the system more (and thus financially speaking cost more), does not sit well with me.  People are not cars.  Not everybody maintains their cars well.  But poorly maintained cars do not necessarily lead to increased accidents and traffic law violations.  Poorly maintained health often leads to a human body’s multi-car highway pile-up equivalents.

My friend advocates for insurance coverage for catastrophic care (also aligned with the car insurance model), but not necessarily for preventive or primary care.  There are different ways of ‘using’ the system. If you get preventive care, like recommended cancer screening and annual exams, it may cost more at the time. If you seek help for your back pain early, from your PCP, chiropractor, and physical therapy, that costs money.  But if these early interventions prevent future, more catastrophic and costly outcomes, should we really penalize those who make them?  Illness and infirmity come with age.  So, often, do fixed incomes.  Is it right to make our elderly pay more for their care?

There are costs and benefits to care other than money, which is where health insurance and car insurance diverge sharply, in my view.  I know they are harder to quantify and assign, but they matter.  That secure feeling that I can get care when/if I need it, that my children and I have access to professionals dedicated to my health and well-being, a sense that in our society, I matter just as much as the next person, regardless of my net worth—these things all matter.  Each individual’s health or illness contributes synergistically to the health or illness of a society.  A mother’s depression, untreated and uncontrolled because her health plan does not cover mental health services, can negatively affect every aspect of her and her children’s lives, emotionally, physically, financially, and socially.  We cannot only look at healthcare on dollar spreadsheets of ‘use.’

Maybe it’s about priorities and philosophy—ideology?  Do we feel all people have an equal right to equal care, or do we differentiate what people deserve based on particular group memberships or other characteristics?  Do we feel we should only be responsible for ourselves, or are we called to look out for one another?  I personally believe in equal access to care and ‘look out for others as yourself.’

I also believe that people need to understand–personally and concretely–that everything does cost money, we all pay for one another’s use (and disuse, and misuse) eventually, and more care is not necessarily better.  So I understand and partially agree with my friend’s argument that people need to have ‘skin in the game’ to control overuse of services for no benefit.  One great example is end of life care.  I like this article from Fobres, which describes the conundrum succinctly:

According to one study (Banarto, McClellan, Kagy and Garber, 2004), 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life.  I know there are other studies out there that say slightly different things, but the reality is simple: we spend an incredible amount of money on that last year and month.

Dr. Susan Dale Block, Chair and Director of Psychosocial Oncology and Palliative Care at the Dana Farber Cancer Institute and Brigham and Women’s Health Care, recently shared some data with her colleagues.  In the Archives of Internal Medicine, a study asked if a better quality of death takes place when per capital cost rise.  In lay terms … the study found that the less money spent in this time period, the better the death experience is for the patient.

 
Cost, longevity, quality of life, quality of care, value, perceptions, public health—these and other aspects of health and medicine are all inextricably enmeshed, though definitely not integrated.  Any decisions about one must be made in the context of all the others, carefully, transparently, and honestly.  Whenever we hear, ‘if we just do this, everything will be better,’ red flags should fly.

I wrote the first draft of the paragraphs above on my Facebook page.  I ended the post with, “So let’s each educate ourselves on the facts, as well as we can, and try to look at the big picture. It’s so messy.  And it’s what we’ve got, so let’s deal with it–with maturity, patience, professionalism, and equanimity.”

Another friend, a fellow liberal, commented, “This has nothing to do with healthcare. It’s about reducing taxes on the wealthy, reducing benefits for the poor, and denying the democrats credit for anything good. If they actually cared about healthcare, they would fix the obvious problems with the ACA. And because the ACA was the republican plan, they will continue to tie themselves up into pretzels to disown it and put something else in place. That being said, I hope the American people continue to demand access to affordable healthcare for all. It’s a right, not a privilege.”

I had to reply: “(My friend,) I understand your point of view, and I share your passion for equality.  But your statement exemplifies exactly the broad brush, ‘you suck’ attitude that I see holding us all back.  I refuse to believe that all Republicans are only motivated by making the rich richer, and that none of them care anything about the poor, as so many of us on the left say.  We must extricate ourselves from this destructive narrative and learn to hold space for everybody’s complex views and experiences.”

My point here is that nothing is as simple as we’d like.  It’s so much easier to blame those who disagree with us for being stubborn, selfish, or evil, than to cope with the discomfort that our system is deeply flawed, there are no easy answers, and our fundamental philosophical differences make it that much harder to agree on the best way forward.  And yet, this is what we are called to do.  It’s up to each and every one of us to change our language.  Each of us has, I believe, the opportunity and the responsibility to create an environment in which open, respectful discussion and debate are the norm, rather than echo chambers and verbal warring.

I am only one person.  I have no designated leadership titles or widely visible platform.  But my words have power.  So do yours.  Please use them wisely.

 

On You, Team Captain and Tribal Leader

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NaBloPoMo 2016, Letters to Patients, Day 29

To Patients Who Think What You Do Doesn’t Matter:

Think again.

Yesterday I described You, the Elite Athlete.  All great athletes know they do not succeed alone.  They also appreciate the unique contribution they make to their teams.  What teams do you serve?  How do you lead?  It doesn’t matter whether you have a title or designation.  One of my favorite ideas is that no matter our instrument in the orchestra, according to Ben Zander, we can lead from any chair.

For now, think of yourself as Team Captain, or Tribal Leader.  You have invested in yourself by fueling and training, resting and recovering, managing your stress, and cultivating excellent relationships.  Now you can take the returns and reinvest in those around you:

Appraise:  Prioritize self-care

  • Like on an airplane: “Put your own mask on first.” Tribal leaders know that to effectively care for others long term, they first need to be healthy themselves.
  • Practice awareness and management of your emotions, and prevent emotional hijacking, so as to be emotionally available to our teammates and tribe members.

Empathize:  Speak the team’s language(s)

  • Think of your favorite teachers and coaches—they were able to relate to learners at all stages of development and team morale—and lovingly lift us all up.
  • “People don’t care how much you know until they know how much you care.” –T. Roosevelt

Inspire:  Lead by example

  • Effective leaders reject victim mentality, take responsibility for our actions, and model accountability for fellow tribe members.
  • When we captains can take our own mistakes in stride, as learning opportunities rather than shameful horrors, we make it safe for our teammates to do the same.
  • Everybody is then free to take more risks, voice more ideas, offer more of their authentic selves as a contribution to the whole,
  • Because they see us, their leaders, the ones who set the tone for the group, doing it, too.
  • Key here also is leading out loud—excellent captains articulate and coach the methods of self-awareness and self-management that help us all succeed.
  • By inspiring individuals to pursue personal excellence, leaders create a supportive milieu for collaboration and collective achievement.

Motivate:  Empower team members

  • Effective captains (coaches, leaders) recognize team members’ strengths and potential, as well as areas for improvement.
  • Rather than shaming teammates for mistakes or deficiencies, good tribal leaders provide feedback and encouragement, and more opportunities for practice and development.
  • They take into account each team member’s personal goals, and help to align them with those of the collective—excellent captains connect individuals to the whole.

If your actions cause others to

Dream more, learn more,

Do more and become more,

You are a leader.

–John Quincy Adams

What would happen if you treated yourself like a true leader?