Decide When You Must

The lavender labyrinth at Cherry Point Farm and Market, Shelby, MI

NaBloPoMo 2021:  Do Good, Kid

“You don’t have to decide right now.”

These words usually cause me relief.  Maybe because I’m a procrastinator at heart?  And maybe because I just don’t like to be rushed into things, and for sure I do not like to be told what to do, no sir.  I will make up my mind when I am damn well good and ready, thank you very much.  Yes, that’s definitely part of it.  

But for many people, putting off decisions (or actions) incites anxiety, no?  Maybe you need a plan, and to feel secure that you know what will happen, where you’re heading?  I think this comes up a lot in medicine, when doctors and patients share decisions on plan of care.  Cancer screening and diagnostic testing protocols seem cookbook on the surface, but in order to make the best decisions for individuals in a large, complex system, we often need to think harder about what to do and when.

In the Knowledge Project podcast episode with Bill Ackman, he considers the utility of putting off decisions.  Just because you can make a decision now, does not mean you should.  Instead, assess and decide when you will need to make the decision.  The question to ask here, he says, is, “When will the risk picture change, and how?”  Basically, how much time from now until it’s do or die?  What factors should I monitor, and what are/will be my options now, compared to then?

What will we do with the information from any given diagnostic test? What are the possible/likely results, and how reliable will they be? Which results will answer our most important questions (what are those questions, anyway? What are our primary goals?), and which will provoke more questions, thus complicating the picture for no benefit? Screening and diagnostic tests are one way doors—once done, they cannot be undone. The information revealed, reliable or not, actionable or not, is now forever discoverable and requiring explanation. Many a wild goose chase are instigated based on benign, irrelevant, incidental findings from unwarranted and excess testing (my opinion). My minimalist bias stems from a deep aversion to wasting resources—time, energy, and access as importantly as dollars. In our quest for certainty, sometimes we get exactly the opposite.

That said, the suites of risk that matter most to you, me, or anyone else are both unique and overlapping, no?  Their weight and prioritization evolve in constant fluidity over time, and non-linearly, which I think we don’t attend to enough.  At the end of many elderly folks’ lives, they prioritize independence and quality of daily life now.  But their loved ones may prioritize safety now and longevity later.  Grandma may be willing to sacrifice months or years lived for staying in her house, and she might also change her mind multiple times before the actual end of life.  She may have a very different framework for deciding when/what/how to do things, compared to Son and Daughter-in-law.  You may be completely willing to risk finding colon cancer at a later, less treat/curable stage, because the intrinsic costs of the prep, sedation, or whatever else about the test are just that high for you.  Or you may be willing to have multiple breast biopsies, risking pain, bleeding, infection, scarring, and increasing likelihood of future abnormal mammogram findings, just so you can be assured every year that you do not have breast cancer now. 

As loving family members and conscientious healthcare teams, we must always negotiate for optimal outcomes, subjective as well as objective.  May we all approach ourselves and one another in respect, peace, love, and mutual support, and hold space when and where appropriate. 

Stay Connected

NaBoPoMo 2021:  Do Good, Kid

My friend Liz is amazing.

We met just as I was leaving my last practice 7 years ago, and I knew right away I had to grow this relationship.  She is an elder sister in the profession—a wise, compassionate, generous, empathic, smart, thoughtful, and loving physician and teacher.  After I had the privilege of presenting to her and her amazing colleagues on physician burnout (really, they schooled me that day), Liz showed me the inner world of primary care in a correctional facility.  We toured incredibly aged buildings.  Liz explained the frustrating limitations of working in a jail environment and the difficulties arranging optimal follow up when detainees are released.  But most of all, she showed me what true, deep respect for every person’s dignity, no matter how vulnerable, looks like.  Holy cow, I will never forget that day. 

Liz is also a deeply spiritual person.  She wrote the chapter on spiritual resources for Jewish healthcare professionals in Judaism and Health.  After our day together at the jail, we kept trying to meet again.  I wanted to learn more about Judaism and how she lived it—personally, professionally, and in community.  But my kids were little and the weather was bad on the nights we planned to meet, or something would come up, or- or- or…  It just never worked out.  But as physicians of deep faith, we both always knew we would connect again someday.

We kept in touch all these years mostly through occasional emails, and then YAY Facebook, especially the Physician Moms Group!  By far the most valuable thing about social media is sharing photos and reading life updates.  It really makes you feel like you’re in your friends’ lives up close, going through all the ups and downs, sharing joys and sorrows, witnessing from afar.  When I posted recently about a freak out I had over Daughter’s anaphylactic food allergy, Liz reached out.

We met in her neighborhood, which happens to be my old college stomping grounds.  We walked all over campus and caught up, shared stories, commiserated, and bonded, just like we always knew we would.  I got a copy of the book with a bonus printout of her favorite poem, “The Seven of Pentacles” by Marge Piercy.  I will return the love with my favorite book of poems so far, To Bless the Space Between Us by John O’Donohue. 

The space between us, indeed.  So near, just across town, yet so far, 7 years, and yet so near still, always connected in spirit through the years, light and strong, like dental floss or fishing line… We stayed connected, patiently, faithfully, knowing that divinity operates on its own schedule, and that when we could finally meet again, it would be powerful and lovely. 

And so it was.

It will not be another 7 years, this we know.  And it was well worth the wait.

Ask For Help

NaBloPoMo 2021:  Do Good, Kid

I bet most practicing physicians can remember a time in their training when, not totally sure of what they were doing, they had to choose:  Ask for help, or go it alone?

Medical culture can give a learner some serious psychological whiplash.  In training, we are told at the same time explicitly that we should ask for help (we are novices, after all), and also implicitly that we should already know everything, that asking for help is weak and makes us inadequate.  It can be a dangerous paradox to navigate, especially when patients’ lives may be at stake.  Do I really know what I’m doing?  I know this attending will make fun of me for asking, say it’s a stupid question.  Is it a competence or a confidence problem?  Do I risk diminishing my reputation or making a mistake?  Bad things happen when we choose pride over safety.

* * *

I need for some extra help at home, but it’s not conventional. has not been helpful.  Then EUREKA, it occurs to me, I have a whole network of smart, connected, creative friends whose combined life experience could yield some shining hidden treasures in this hunt.  So I queried them all at once via email; the response was immediate, and just the trove that I needed.  Considerations here, resources there, and insightful questions that broadened my perspective on what I need.  When we ask for help from a loving community or tribe, we get so much more than information.  We receive encouragement and learn about our friends.  We strengthen our connections, which feeds both the helpers and the helped in meaningful ways that really last.

* * *

One profound benefit of COVID, if you could call it that, is significantly improved access to metal healthcare.  The isolation and loneliness, the utter chaos wrought by pandemic living, has pushed so many of us to the edge of our sanity.  But precisely because of the pandemic, now we can do our therapy sessions remotely, by phone or video.  No more carving out commute and parking time once a week, among other obstacles.  Pre-COVID, therapists and medical clinicians were never reimbursed adequately for remote care, so we thought it could never be done, no matter how much it would serve both practitioners and patients.  Non-synchronous, online psychotherapy thankfully had its advent in recent years, so now more people can connect with mental health professionals from home or work, at their own convenience, making contact exponentially easier.  Cost and availability still keep many from getting the help they need, but many more are connecting now than before.  I have said for a while now that we should each just be assigned a therapist at birth.  Life is hard, and we don’t always learn the coping skills we need from our families or at school.  Mental health professionals today are like fifth generation hardware store owners—they possess evolving and historical knowledge.  They wield myriad tools to help us solve problems; they can show us how our own plumbing works.  They help us learn which hammer or wrench to choose when we see, hear, or feel something off in our house.  But we have to seek them out, to ask for their help.

What have you been facing all alone lately?  Who could help you?  When will you ask them?