Category Archives: leadership

Stress Management

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Anybody else feel daunted thinking about stress managment lately? [wide eyed emoji]

It’s November of the hardest year in my recent professional memory, and the escalating stress levels I witness every day show no signs of abating. My patients are sleeping poorly, gaining weight, and their blood pressure continues to rise. They miss quality time with loved ones and rethink their life paths more seriously now than ever. Strangers on the street seem increasingly confrontational. The world is once again embroiled in war and violence. Our stress management skills are called forth, no question.

I attended the second ever Harvard Medical School coaching conference in the spring of 2009, where I met Benjamin Zander and The Art of Possibility became my personal development bible. Roz Zander, co-author, former wife, and decades long collaborator to Ben Zander, died suddenly this year. I hope my writing and impact may honor her, as these 14 years of my inner and outer work, sparked by the Zanders at that meeting, made me a better person that I would otherwise have been, founded on the practices in their book.

**Deep breath**

It’s been at least a decade, and I still ask patients to assess work stress in terms of threat and challenge. Threat stress–basically fight or flight–is physiologically taxing, meant to last seconds (not years), and costs us our health if prolonged. Challenge stress is activating, productive, and beneficial. I also query about personal fulfillment from work–meaning. We can tolerate very high levels of stress, even prolonged threat, if it’s worth it to us.

Parenting may be a better example than work. When we fear for our children’s well being, and even their lives in crises, how do we manage that? Is there any worse threat? We’d all rather it be ourselves suffering than our kids, right? How do we cope when we have no control?

At the risk of sounding arrogant, I feel very confident in my stress management skills. This is not to say I don’t experience severe stress or feel its consequences. I just move through it much more easily and with a lot less suffering now than in the past. I feel a lot less threat than challenge. Briefly, the practices:
—Breathe. Ever since my first medical assistant posted “TAKE A DEEP BREATH” at my workspace, I have appreciated the calming effect of one deep breath, physically and psychologically. We can breathe ourselves through childbirth, injury, emotional trauma, and myriad other urgent and emergent situations. Deep breathing stimulates the de-escalating parasympathetic (rest and digest) nervous system, balancing the autonomic hijack mediated by the sympathetic system. I breathe along with patients when I listen to their lungs. I inhale deeply when listening to books, and during strenuous exercise. It is my central grounding practice.
—Accept. “It is what it is.” This has nothing to do with how I feel about it. But the sooner I separate what is from what I want it to be, the less I suffer. Obviously I find this much easier to do for things I care less about. But even for big things, like the state of our healthcare system, the brokenness of our government, and my estimate of the ultimate demise of humanity (I think five more generations, give or take), just being with what is, as a first step to figuring out what to do next, helps me suffer a lot less.
—Withhold judgment. I’m really good now at not jumping to conclusions and not making sweeping judgments about people based on limited information. I am able to separate judgment of actions from people’s character and humanity. If you’re screaming at my team and me, you are clearly unwell. We can hold you accountable to your actions and still show you compassion and respect. I don’t have to think you’re a bad person. This way, I don’t take your negative actions personally, and I can stay calm and even.
—Get help. I ask every patient every year about their emotional support network, because it matters. Mine is phenomenal and I could not be more grateful. But I only know they are so because I call on them enough and they on me. Rarely I am disappointed, and I learn to turn elsewhere. I cannot overstate the profound importance of tribe and connection. It is my raison d’etre.
—Move. When daughter was admitted to the hospital and I stayed with her there, I made sure to get on the ellipitical each day that week. When I go too many days without movement, I get edgy and stuck in my thoughts. My stress is exponentially more manageable if I protect my workouts, which I have now done for many years.
—Attune and differentiate. My greatest stressors involve other people. Friction, tension, grating, colliding, etc. Since my LOH leadership training helped me articulate these complementary concepts, I recognize now that attuning/aligning with others, as well as differentiating and standing firm in my own core values and practices are equally important and fluid in their dynamics. Feeling out that optimal integration in any given interaction is rewarding in itself, and the outcomes are always better when I attend to both, knowing that I am showing up true to myself. What more can I ask of me?

So what could be better? Anything, really. For the rest of my life, new stressors will continually emerge. In his book Master of Change, Brad Stulberg quotes a statistic that in an average adult life, we will experience 34 major disruption events, which works out to about one every 18 months. Sounds about right to me! So I can expect to be challenged and trained in all of these skills and more, usque ad mortem. I only hope I can keep learning, applying, improving, and growing. Bring it.

—

I feel less harshly about our collective, societal stress management skills and outcomes than I do about our obessions and ironies with exercise and nutrition. Really, I think everybody’s doing the best they can, with the skills they have, in the circumstances of their lives at any given time. I just wish our environments didn’t create and perpetuate so many of our stressors in the first place.

So what’s already good?
—Potential. We are all surrounded by one another. So every encounter, any time, any place, is an opportunity to do people-ing better. In any given relationship, if anyone is willing at all, there is always the chance for repair after rupture. Humans are innate learners; we can continually acquire the skills to stop impaling ourselves with the second arrow of suffering, after the arrows of pain hit us in daily life. We can even hold one another up and heal our injuries together.
—Books, teachers, resources. Those aisles and shelves of stress management books really are dense, and I can say with conviction from first hand consumption that the knowledge and potential benefit living in those pages is immense. For those with the bandwidth to actively seek, consume, digest, and apply, lives can be transformed, especially if shared, discussed, and practiced together.
–Sometimes it really doesn’t take much. Your friend calls to check on you. A stranger helpsy you carry your groceries. When we say ‘it’s the little things,’ we speak truth. Small acts of kindness and incidental connections will not solve our hardest problems, but we must not underestimate their profound potential to help, and for that help to amplify in unexpectedly large ways. What’s more, both the helper and the helped benefit from the encounter.

What could be better?
–Teach it explicitly. There is a movement afoot among Dialectical Behavior (T)herapists to formally incorporate stress management skills into school curriculum. DBT organizes life skills around four central pillars: Mindfulness, Emotional Regulation, Distress Tolerance, and Interpersonal Effectiveness. Within each module are sets of practices, many with campy acronyms to help us remember. I refer patients to the DBT skills website often, not just to help them cope better themselves, but to help them model better coping skills to their children, direct reports, and leaders. Simply having the confidence that we can handle whatever comes our way, because we know what to do, decreases stress exponentially. What if we learn these skills in childhood, before the chaos of adolescence and serial tumult that is adulting? Can you imagine?
–Relational Leadership Training and Valuation. Leadership done well is a practice in empathic, compassionate, accountable, and transparent stewardship. It is a way of being and doing, one that requires high level self-awareness and self-regulation, and excellent attunement and communication skills. Right now I think leadership training focuses a lot on transactional communication, superficial team dynamics, and not enough on building leaders’ stewardship mindset and deeper relational skills. We should require evidence of these skills for promotion and provide communal support and feedback to strengthen their practice. This would reduce overall stress in organizations by building cultures of empathy, compassion, accountability, and transparency from the top. Workers’ stress, in my observation, stems in large part from toxic cultures set by relationally inept leaders.

So, another plot twist, but maybe not really. My solution to stress management optimization is relationship-centered: first relationship with self, then between self and others, and then between/among those who know us, by way of example setting.

Stress is complex. Its optimal management is a lifelong practice. It’s never too late to start, and no skills practice is too small or wasted.

“The only way out is through. The best way through is together.” I think that applies here.

The Future of AI in Medicine

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What do I know about AI?  Next to nothing.

So why would my colleagues at the American College of Physicians invite me to speak in a panel discussion on AI in primary care?  It was a mystery to me and yet I agreed, because hey, I like feeling wanted. And I trust my ACP friends.  They know me and they knew what the panel needed.

The meeting was this week.  Daughter got sick, Husband was out of town, and I chose to stay home.  I thought, ‘Nobody will miss me, I don’t know anything anyway.’  But through the wonders of technology, I was able to participate via Zoom, yay!  And I did end up contributing, as the one clinical physician panelist.  It was fun and connecting, despite my being remote.  I recognized two former colleagues during Q&A just by their voices, and another texted me from the audience after she saw me on screen.  This technology Luddite may yet be converted.

I share here a summary of my learnings and perspective on AI in medicine at this moment—I have many more thoughts about it than I realized!  I wonder how long before it all changes?  I bet not as long as I think.

Current State

Dr. Steven Lin is now my favorite clinician writer on the possibilities and pitfalls of medical AI, and in primary care, specifically.  For two excellent and concise summaries, read an internal Stanford interview from 2019 and his original article from the Journal of the American Board of Family Medicine in 2022.  Some visual highlights from the latter:

Mission: To Enhance, Not Replace, Human Care

Intelligence is complex, and none more so than the human.  We are amazing!  For simplicity’s sake let’s just divide human intelligence into cognitive and limbic—thinking and feeling.  Intuitively we probably all understand that ‘artificial intelligence’ refers to the former, activities that can be replicated using concrete and objective data and logic.  Algorithm implementation and machine learning already enhance diagnostic accuracy, clinical decision making, and risk assessment and management.  AI even delivers health coaching now, with encouraging results.  Triage, access, billing, and follow up processes will all likely improve in the coming years with AI.  I welcome the streamlining and appropriate simplification of our enragingly labyrinthine healthcare systems.

Still, patients will always need personal encounters with clinicians who provide services and care.  But when were you last able to reach your primary care provider directly and quickly?  How long do you have to wait for an appointment when you’re sick?  If you answered, ‘recently’ and ‘not long,’ you are in the vast minority.  How well does your primary care doctor know you, if you have one at all?  So many patients have given up on establishing this bedrock healthcare relationship, because the system makes it next to impossible for you to talk to me when you’re sick, my schedule is booked solid for three months so I can’t see you anyway, and when I do see you, I only have 15 minutes.  It’s like speed dating with earplugs and snorkel masks.

AI will never know and interact with humans on an emotional, relational level.  What it can do is remove the transactional, clerical, algorithmizable(!) tasks from clinicians’ plates, so we can sit and talk with you, see and know you as a whole person, and care for you in the most personalized ways.  AI can learn which of you has a lot going on medically, who needs extra time and attention. But only a human can deliver that attention in a way that truly cares for and heals you, especially if your health needs are complex.  And the more AI shows us what’s needed, I suspect we will need many, many more intellectually, emotionally, and relationally competent clinicians in all fields to answer the call, which is a whole other mountain unto itself.

Data: “Garbage In, Garbage Out“

Applying populational data to individual decision making has always been both science and art.  AI can enhance this very personalized activity by making vast amounts of data easier for clinicians to access and interpret in real time patient care.  But beware big data:  How is it collected?  How do we measure and confirm its accuracy?  How is it entered, organized, aggregated, interpreted, used?  Who decides all of these things, and what interests do they have?  Who will monitor for bias, equity, and unintended adverse effects on certain populations that are inherently, if inadvertently, built into AI systems at the level of design?  This is where I really see us falling down and not even knowing, and then ignoring and dismissing those who call it out.

Governance: Honest, Transparent, and Accountable

After we answer the question of who will monitor, we must ask and answer how.  The American healthcare system is fundamentally capitalist and increasingly consumerist, an extremely high-risk combination.  Bad actors will certainly subvert the mission of individual and collective health and well-being to make more money.  But possibly more dangerous are those who honestly believe they are out to help people and who, despite their best efforts, succumb to economic and cultural pressures to put profits (or market share, or personal status, etc.) ahead of professed altruistic mission.  Short term financial and social costs of inventing, experimenting, and iterating innovation can be intolerably high, and too often those in power and regulatory positions act on primal (though well-rationalized) instincts to forgo those costs to protect and advance other interests.  At our core, we humans are emotionally driven decision makers who then justify our actions (often vociferously). Only when we accept this reality can we hope to regulate our systems honestly, transparently, and with true accountability.  I feel deeply cynical about the likelihood of us doing this at all effectively.

Agility and Evolution: Lightning vs. Glaciers, Integrated Co-Creation, and Emergence

Technology moves increasingly at lightning speed; medical knowledge doubles now about every 4 years, compared to every 50 years in 1950.  Medical culture, on the other hand, moves at a glacial pace.  I’m thinking of gender and racial equity, holistic mental health, and mind-body awareness and practice.  To avoid harms and fully benefit from the inevitably rapid evolution of AI, we must build systems that foster invention, experimentation, and iteration at local nodes (team, practice, department, hospital, health system, etc), strengthen multidimensionally integrated and transparent internodal communication structures, and maintain monitoring processes that can detect common, coincident AI benefits as they emerge, so they can be efficiently, effectively, and appropriately scaled.  At the same time, solutions must be flexible enough to adapt and iterate on a global level, as shared learning marches onward.  This open-source and resource-intensive style of collaborative innovation feels antithetical to the competitive, short term profit-driven American healthcare business culture.  I see this challenge as especially inextricable from the accountability problem of AI governance above. Yikes.

Medical Education:  Leading and Learning by Example

Sometimes I wonder if technology is making us all dumber–like maybe safety features on modern cars makes us fundamentally less mindful drivers?  We clinicians all have Google and UpToDate at our fingertips; accessible information 24/7.  Almost every day, I look things up in real time during a patient encounter—did you know some people grow more lipomas if they drink more alcohol?  There is just too much information now to keep it all in my head.  I feel comfortable thinking out loud with patients, talking through basic physiology and how it may relate to or explain their symptoms.  When I come across something novel or atypical, as long as the patient is stable, I feel a little exhilarated, like we’re going on a themed scavenger hunt for diagnosis and treatment.  This is exactly where AI can optimize care, by gleaning the vast seas of medical information and knowledge, filling the gaps in my head that will only get larger over time.  It gives me more bandwidth to ask better questions, listen longer to patients’ answers, and explain increasingly complex plans of care better. 

Having trained on the cusp of the information age, I wonder how/whether my thought processes differ from, and how that affects my relationship with, younger docs?  Medicine has always been an apprenticeship profession, and we have always felt social generation gaps that mirror society at large. I think that will not change. What has changed–narrowed–is the information/knowledge gap. 20 years ago, my teachers consistently knew exponentially more than I did about almost everything. I think those days are long gone. Any student today who just rotated through any given medical subspecialty will know more than I do about new diagnoses, drugs, and procedures. I am totally okay with this–there is so much to learn, I should get it wherever and from whomever I can.

Teachers and mentors, however, hold experience, intuition, context, and judgment that can only come with cumulative time spent in practice. This is what we have to offer our trainees–the example of curiosity and humility for lifelong professional and personal learning. As AI accelerates and infiltrates our systems, teachers must role model critical openness, mission- and relationship-centered integration, and an agile, honest, growth mindset. None of us will ever now know it all. Optimal patient care merges expert knowledge with presence, attunement, wisdom, and connection–machines cannot do or teach this, and we must all help one another figure out how best to incorporate machines into patient care.

Cautious Optimism

Primary care has the greatest potential and privilege to see, hear, and touch every other medical specialty, and all aspects of the healthcare system at large. Wow. How could I not love this work? What fascinating and rewarding polarities to navigate–tradition and innovation, conservation and progress, intellect and relationship, strategy and vocation. I have no complete (or even well-formed) answers, only reflections. I know where my values and goals live, though, and I root down to them. If we can do this as a profession and a society, then AI’s potential to make all our lives better could be limitless.

The Joyous Liberation of Radical Acceptance

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Happy Happy 50th Birthday to me!

I’ve been 50 for over two weeks now and could not be happier about it! Do I obsess about my age? Maybe. But whatever, I’m having a great time and it’s all because I’ve lived long enough to acquire some wisdom, and may yet live a while longer to exercise it all. What a privilege and a joy.
Middle age. Awesome.
I’m like a vintage car now. If I wanna keep driving smoothly, I’ gotta invest in the maintenance. My value continues to grow, and I can revel in some positive attention I get for being my real, colorful, sparkly, strong, BOOBS OUT, middle aged self.

Why is aging so difficult to accept? Why do we resist so fiercely?

Maybe we equate acceptance with resignation? Is it a conventional fallacy, like if we admit that we are ‘old’ then by definition we are decrepit and obsolete, that only young people have value in and contribute to society?

Maybe it’s how we define ‘old’? Is 50 old? Is 30? 80? Is it a number, a mindset, a set of abilities? Does it matter?

Patients often ask me what they should expect to be able to do and not–usually physical things–based on their age. It’s impossible to answer, as each person is unique; and it’s not just about chronological age. It’s about what’s worth doing for each of us. What are your goals, how important are they to you, and what trade-offs are you willing and not willing to make to achieve them? What factors would alter these calculations? What are you willing to risk? What will you regret if you don’t get what you want, or hurt yourself (and/or others) in the pursuit?

What do you need to get to peace with your age, and the state of your body, mind, relationships, and life expectancy? Where can/do you still act with energy and power, despite new and cumulative constraints? What’s great about the now, and how can you maximize that, amplify and spread it?

Resist. Deny. Reject. Oppose. Deflect. Energy spent on these diversions is counterproductive, wasted. It keeps us tethered to exactly the thing we refuse to acknowledge. Opposition and denial are unidimensional and static. When I fight against an unwanted reality, it’s all I see, my sole focus–even as I actively deny it–how hilariously and tragically ironic. I show up tense, defensive, in fight or flight survival mode–often without knowing, or in metadenial–denial of my denial. I get nowhere and I’m all uhnappy about it. We are funny, we humans.

When I accept the thing, I can put it down, let it be. Even if I disagree with and dislike it, even if it causes me pain. Unburdened from carrying it (even as I deny carrying it), I can loosen my neck and shoulders, look up, breathe deeply and ask, “Okay, what now? What next?”
And here is where the magic happens.

Acceptance is dynamic. It liberates. When I stop denying, rejecting, and opposing, then I’m free to question, explore, discover, choose, invent, experiment, connect, and move.
Acceptance is the birthplace of possibility.

Anger, jealousy, self-loathing, grief, sadness, conflict, uncertainty, other people’s inexplicable behavior, your aging body: Allow it. Embrace it all. Hold it lightly and loosely or put it down, or just nod respectfully and leave it. We can choose this: to suffer less by simply accepting first. We get to decide then, consciously, what orientation to any reality is most consistent with our values, goals, joy, fulfillment, and peace. We do this by seeking the best questions instead of the usual ones. Make them open ended and relevant to you, now, here, as well as to your future best self. Talk things through with people who love you for who you are, who don’t judge, who accept you, whom you trust, and who will also hold you accountable.
Self-acceptance is fundamental and essential for a life of peace, and no less vital are true belonging and deep, honest communion with others.

OH I finally get it, I think! For so many years I have grappled with this paradoxical and counterintuitive idea that acceptance is the foundation of peace and change, and today I think I reached a new overlook on the climb. Acceptance is not resignation or wallowing; it is not tacit endorsement of what I don’t want. It is simply being with what is, including how I feel about, dispelling my self-delusions about the current reality. It is also understanding that that reality can and likely will change, and though I may not have control, I have agency: I can absolutely influence the direction of that change. And I don’t have to be grumpy and adversarial while I act–I can choose to do it all joyfully. How exciting! I am ready, let me at it!