Category Archives: leadership

What Emerges from Crisis:  Connection, Learning, and Contribution

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“What observations/discoveries/learnings have you noticed in these weeks?”

In phone calls, emails, and snail mail to friends, I find myself asking this question repeatedly.  This exercise yields two wins:  1) I’m connecting to my people all across the country; 2) I get to answer for myself, and new insights emerge each time.

How are you connecting with your people in these weeks of physical separation?

What have you had to reframe, create, and experiment with to make life work in our sudden new reality?  How does it feel?  What are you learning?

* * * * * *

 Inconvenient Emotions

Very early in the pandemic, when I realized my clinical volume would drop to practically nothing, I started to feel something akin to survivor’s guilt.  I still feel it—I am not on the front lines; I myself am not in harm’s way, as so many of my colleagues are.  I feel relief for not having to be there (yet).  Then I feel guilty for feeling relieved.  So I try to make myself useful, giving Zoom presentations on wellness to colleagues and firesides on Instagram for the public.  Life has settled into something of a routine.  I do video calls, helping with operations management and team organization from an armchair (standing desk).  Turns out I enjoy working from home!  And I feel guilty for enjoying anything about this time of unprecedented global disruption.  Hello, mental and emotional whiplash, my inescapable human companion.  Thankfully, self-compassion practice keeps me sane.

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Acceptance with Agency

“The first step to changing your circumstances is to accept them.”  Wut?  I have grappled for years to understand this concept; today I think I finally got it (thank you, Donna!).

Today I choose to define acceptance as a state of possibility, rather than of resignation or victimhood.  Sometimes it helps to describe something by pointing to its opposite:  What happens when we refuse to accept what is?  Often we cling to what we think should be.  What should be is a narrow set of unmet expectations that keeps us anchored to the past, or at least to an unreality that simply does not exist.

What happens when we finally accept what is?  We are liberated to ask some important questions:  How do I feel about what is?  What are the best and worst potential outcomes from here?  What do I want to be different?  How can I effect that change?  What is my work here?

Accepting what is brings us over the threshold from the narrowness of what should be to the wide possibility of what could be, where our agency is what we make of it.

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Optimism + Cynicism = Peace

Some days I get so excited, reveling in human ingenuity and resilience!  Look at the transitions we all made, practically on a dime, moving healthcare and education online, organizing COVID testing and creating treatment protocols, constructing hospital wards in convention centers, initiating clinical trials, and sharing experience and data internationally at breakneck speed!  All this learning and application, holy cow, how could we not be smarter, more connected, and better after all of this?

By being human, that’s how.  Despite our great capacity for survival and adaptation, we are creatures of habit and products of our environments and relationships.  We revert more easily than we convert.  On cynical days I think, “Nothing will change.  We will stay the same stupid species we have become, just a couple hundred thousand deaths closer to our own stupid, eventual extinction.  And we will deserve it.”

Here’s the fascinating thing, though:  I vacillate in this false dichotomy lightly, even though the emotions on both sides can get intense.  We humans are such a complex enigma, capable of profound love and selflessness, and also unfathomable hatred and destruction.  That’s simply what is—we are all of these things, intricately complicated in our nature.  Each one of us possesses an infinite set of potential vectors for connection and/or destruction.  But I still get to choose what to do with my time, energy, and resources in this lifetime.  It’s my call.  So I’m okay; I’ got this.

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Co-Creation:  The New Normal

The last two years I have had the privilege to work with colleagues around our vision, mission, and values.  I have studied various work cultures, observed and interviewed associates and teammates.  LOH taught me the language and framework to synthesize my own, evolving style of relational leadership.  During this downtime—this unearned vacation—I have time and space to consider a bigger picture.  What about our culture best manifests our mission and values?  How did this facilitate our successes in reorganization and mobilization?  What held us back?  What needs to happen (change?) in order for us to emerge from this crisis in learning and growth, rather than in fear and trauma?  These questions apply professionally, personally, and societally.

My strengths lie in relationship and connection.   Throughout this long journey to flatten the curve (and it will be months), I can contribute my insight, observations, and talents at synthesis, creativity and vision, to make our new normal as mindful, intentional, collaborative, and functional as possible.  I can paint a vivid picture of where we could go.  I can embrace dissenting voices and find alignment in apparently divergent interests.  I can help us be better.  This is the contribution I can make.

What will your contribution be?

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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.