Frass, Trauma, and Other Stuff

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NaBloPoMo 2018:  What I’m Learning

Can’t think of anything useful to write today…  Or rather, I’m too tired to make any half useful thoughts into enough coherently connected sentences to be worth publishing.

So I’ll share some small things I have learned recently, which I find interesting.

Frass

Noun.  Fine powdery refuse or fragile perforated wood produced by the activity of boring insects.  The excrement of insect larvae.

I have a wonderfully smart and kind friend who conserves paper for a living.  Do you know any expert paper conservators up close and personal?  If so then you know the exquisite mind and temperament it takes to do this work.  She must possess the exacting scientific leanings that comprehend both biology and advanced chemistry (inorganic and organic).  She holds the vast sweep of art history, especially as it applies to paper and ink as media, at her fingertips.  And her appreciation for the uniqueness and intrinsic value of every piece drives her pursuit of the end product.  She must command all of this knowledge in an integrated fashion, bringing to each new project confidence, curiosity, and love.  And when she works on an old map in the library archives caked with dust and soot, and tells her friend about the project, she teaches her friend the word frass.

Getting out tree sap and other cool tips

You probably already know about using Coca-Cola to clean toilets, and salsa or ketchup to shine pennies and silver.  But did you know that olive oil and butter get out tree sap, and mayonnaise gets off glue residue?  Unbrewed coffee grounds absorb mildew if you leave them in an open container at the bottom of a closet for several days.  Vodka works well for getting smells out of clothes.  And rubbing your hands with salt can get out the smell of onion or garlic.

Toxic gaslighting

I only learned the word ‘gaslighting’ after the 2016 election.  *sigh*

The word was among the final contenders, apparently, for the Oxford English Dictionary’s 2018 Word of the Year.  But ‘toxic’ won.  Says the head of the company’s US dictionaries, “the word was chosen less for statistical reasons, she said, than for the sheer variety of contexts in which it has proliferated, from conversations about environmental poisons to laments about today’s poisonous political discourse to the #MeToo movement, with its calling out of ‘toxic masculinity.’”  Last year’s WotY was ‘youthquake.’

Trauma

Last weekend I spent time with a wonderful residency classmate and her amazing family.  She is the Chief Medical Officer a large health system that serves a population with a high prevalence of mental illness and substance abuse.  I got to hear about her passionate and profoundly important work educating and advocating for trauma-informed care, which I am only starting to learn about.  Interestingly, NPR had just posted an article detailing findings of a study published in the Journal of the American Medical Association (JAMA) showing that childhood trauma is strongly associated with poor adult function outcomes, such as mental illness, failure to hold a job, and social isolation.  By age 16, 31% of children in the study had had one traumatic exposure, 22.5% had had two, and 14.8% had had three.  What does that look like at the doctor’s office?  Read the Harvard story of the two kids and their vaccines here.  What can we do about it, as physicians and society?  First, recognize the prevalence.  NPR asked, “Should childhood trauma be treated as a public health crisis?”  The answer, unequivocally, is yes.  Second and always, practice curiosity and empathy. Every day.  All the time.  Again and again.  If someone is acting out, before judging them for being difficult and ruining your day on purpose, ask what could lie behind the behavior.  Everybody deserves and benefits from a little concern and gentleness. And if you’re a healthcare professional, start with the Harvard article, and then read this one from the National Council for Behavioral Health.  We all need to treat each other better.  So much better.  Please.

So, what interesting thing(s) have you learned lately?

Less Phone, More BOOKS!

books 11-3-2018

NaBloPoMo 2018: What I’m Learning

Hi, I’m Cathy, and I’m addicted to my phone.

Last month I finally decided to do something about it, mostly so I could be more present to the kids.  It’s been a fascinating journey so far, and I’m proud to say I’ve already made progress.  First I banned Facebook after 6pm.  That went well until I traveled.  Then I took the Facebook app off of my phone.  The withdrawl continues to spike at times.  I also notice that I use other things to substitute—New York Times, email, Washington Post, email, WordPress Reader, email.  I notice an anxiety, a frustration, a kind of crazed, darting hankering– I crave that dopamine hit.

The awareness of it all, however, and the commitment to get disentangled from my screen, has cleared space for a recently dormant impulse to surface afresh:

READ!

* * *

At the conference last month I was turned on to the idea of complexity (or chaos) theory and how it relates to fixing physician burnout and turning our whole medical system around.  It was positively mind-blowing (for me—most others did not seem quite as lit).  The speaker was Anthony Suchman, my newest hero.  Some highlight ideas:

  • Every system is perfectly designed to get exactly the results it gets. Our current healthcare system evolved to this point precisely from serial and cumulative decisions made over years, even though the current state was never the intent.
  • We think of organizations as machines, with predictable, linear consequences of adjustments in one part or another. This is rarely how organizations (of people) actually work.  Rather, we can think of organizations as conversations, and let go our expectations of particular outcomes, the illusion of total control.  We can let things unfold and go where the outcomes lead us, all while holding to core values and goals.
  • Patterns are (re)created in each moment, and also self-organizing. So at the same time that a pattern (eg culture) seems inevitable and self-propagating, sometimes small, almost imperceptible perturbations can create new and dramatic cascades that lead to transformation (the butterfly effect).
  • Emergent Design thus embraces the approach of “finding answers we are willing to not know,” trusting that we will get where we need to go simply because we are paying attention (or that’s how I interpret it today).

This theory that everything within a system both results from and also contributes to the whole system (a fractal) validates an idea I have been advocating to my patients for years, and that I continue to personally relearn ad nauseam: It’s all connected.  The most concrete examples are Sleep, Exercise, Nutrition, Stress Management, and Relationships—I used to call them the 5 Realms of Health; now I call them the 5 Reciprocal Domains.  Each one is inextricably connected to every other one, and they all move in concert, with subtle or dramatic dynamics.

books 11-2-18

I browsed around my local bookstore a couple weeks ago and came across a colorful title on the shelf: Emergent Strategy by Adrienne Maree Brown.  So of course I snatched it up.  The blurb says:

Inspired by Octavia Butler’s explorations of our human relationship to change, Emergent Strategy is radical self-help, society-help, and planet-help designed to shape the futures we want to live.  Change is constant.  The world is in a continual state of flux.  It is a stream of ever-mutating, emergent patterns.  Rather than steel ourselves against such change, this book invites us to feel, map, assess, and learn from the swirling patterns around us in order to better understand and influence them as they happen.  This is a resolutely materialist “spirituality” based equally on science and science fiction, a visionary incantation to transform that which ultimately transforms us.

Holy cow, YAAAAS!!  I could not wait to read it!  So I bought it, along with Make Trouble by Cecile Richards, What If This Were Enough? By Heather Havrilesky, and The Dharma of “The Princess Bride” by Ethan Nichtern.  I had also ordered Leading Change in Healthcare, coauthored by Dr. Suchman and two others.  That copy arrived last week.

Suchman 1

I feel this as all part of a slow turn, getting off my phone and diving into books again.  I’m so excited.  I have done this before—buy a bunch of books and never read them.  They occupy whole shelves in my bedroom.  But I honestly feel a transformation coming on.  Yesterday I spent a couple hours reading, researching, and writing the blog post, then I turned off the computer and opened Brown’s book.  I read through the long introduction and resonated with sentences like, “Emergence is the way complex systems and patterns arise out of a multiplicity of relatively simple interactions.”  This is a quote from Complex Adaptive Leadership: Embracing Paradox and Uncertainty by Nick Obolensky (which I have also now ordered).  I also love (ha!), “Perhaps humans’ core function is love.  Love leads us to observe in a much deeper way than any other emotion.”  Also:

all that you touch

you change

all that you change

changes you

the only lasting truth

is change

god is change

That is a quote from Parable of the Sower by Octavia Butler.

Then before bed I opened Suchman et al’s book and found these words, also in the introduction:

Complexity theory here is enriched by the focus on relationships [Hallelujah!], rather than the more traditional reference to science.  “Relationship-Centered Care” is a way of thinking that brings love and all that is personal into a world, the world of healthcare, that is mostly interested in more control and more data-based, evidence-based practices.

The point is made throughout that administrators cannot bring real change into their healthcare institutions without going through change themselves.

(The book describes) the relationship-centered social dynamics that are at the heart of Lean and a major source of this method’s success.  Unfortunately, these social dynamics are overshadowed or even displaced by the analytic technique in some Lean implementations, compromising results.

Suchman 2

So I’m learning about new ways to think on change.   It’s changing how I approach trying to change my patterns, how I see my relationship to them, how I see all relationships.  Wow.

All of this to say, I feel a deeply personal, yet global and cosmic impulse for growth, for transformation—a shift into more mindful and intentional use of my time and energy, and how I manifest it outward.  Less distraction, more focus.  Less incidental information consumption, more integrated learning and coordinated application.  Less phone, more BOOKS.

What will be the outcome?  I have no idea, that’s what makes it so exciting and wonderful!  Onward!

 

How Not to Engage

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NaBloPoMo 2018: What I’m Learning

My friend Alex* posted about being a nurse and how she loves it despite having to always hold her pee, skip lunch, and get bled on, puked on, peed on, and yelled at, all while missing her family and taking care of yours.  One of her friends, we will call him Greg, commented that until nurses unionize and demand professional respect ‘just like physicians,’ nothing will change.

My impulsive (GRRR!) response:  “Trust me, physicians are struggling, too. I propose that we stand up for one another. Then we’d really be a strong force. And in the end it benefits us all–doctors, nurses, patients, the whole care team and, most importantly, patients. Also, I don’t know of any unions that physicians can join, but there are ones that nurses can: https://nurse.org/articles/pros-and-cons-nursing-unions/”  Okay, I know, saying, “Trust me,” is not a good way to get someone to trust or listen to you.  And my reply was defensive in its origin.  I sincerely believe what I wrote, though, that allied advocacy is an untapped force for good in medicine.  Physicians, patients, nurses, all healthcare professionals—why should we not actively support one another in all of our efforts to achieve a more cohesive, efficient, fair, and collaborative system, one that works better for all of us?  Why can we not embrace our connections and combine our voices to call for change?

Greg replied that basically he does not believe that physicians are “struggling,” and he does not see how we would stand up for one another.  After Alex described that I’m a physician “who will always help the nurses,” he wrote that doctors “can’t be in the business of supporting nurses.”  That we should “be in the business of supporting” ourselves, and “from all the research I’ve ever seen, they’ve continued to do a pretty good job of it.  Good for them.”  He expressed support for physicians’ right to advocate for ourselves.  In each reply, he continued to make his point that nurses should unionize.

I find this thread fascinating.  There are so many ways Greg and I could interpret each other’s replies.  When he talks about demanding respect ‘like physicians’ through unions, what benefits and outcomes does he imagine will follow?  When I say “struggling,” I wonder what he thinks I mean?  Actually he asks me, “How exactly are physicians struggling?”  He goes on to write, “Nurses are nurses and should be for nurses.”  All of his comments and the tone I inferred from them caused me to beg off of the thread.  Too bad, it might have been an interesting conversation—if we could have it in person.  Maybe we can later.

But it motivated me to look up some information to post here, in case anybody wonders ‘how physicians are struggling.’  The answer is burnout, depression, suicide, and leaving work that we love because it simply costs us too much—and I mean costs other than money.

Physician burnout is well described and referenced.

Doctors suffer from burnout in especially high numbers, according to the study, which was designed to offer a representative snapshot of doctors and the general U.S. working population. Nearly half of U.S. physicians – 49 percent – meet the definition for overall burnout, compared with 28 percent of other U.S. workers. More than 54 percent of doctors have at least one symptom of burnout, a more detailed analysis found.

Doctors also register more than one and a half times the general working public’s rates of emotional exhaustion and depersonalization. Working a median 50 hours per week, their satisfaction with work-life balance is far lower than that of others: 36 percent versus 61 percent.

medscape burnout causes 2018

Medscape Survey 2018

There are myriad causes for physician burnout, and most of them lie in the system, not in our inherent lack of resilience or because of some intrinsic defect in our collective character.  The electronic health record has accelerated our dissatisfaction with work.  It does so by creating innumerable clicks to accomplish menial tasks, burdening us with data entry that detracts from actual medical decision making and patient care, and putting a physical barrier between us and our patients, further separating us in relationship.  Burned out and dissatisfied doctors are distracted, less empathetic, and aloof, and we may even make more mistakes.  And when we aren’t well, our patients aren’t well.

A 2015 Mayo Clinic study reported that roughly 40 percent of physicians suffer depression each year and almost 7 percent had considered suicide within the prior 12 months. It is estimated that 300 to 400 doctors take their lives every year.

The pain and suffering those statistics only hint at is bad enough. But they are compounded by findings that burnout corrodes the doctor-patient relationship, resulting in lower levels of patient satisfaction, job satisfaction and productivity, as well as higher levels of medical errors and disruptive behavior.

Burnout is also connected to the decision to switch jobs or leave medicine altogether — an ominous trend as the U.S. experiences a growing doctor shortage.

 

I have not addressed here the challenges that nurses face every day.  My mom is a nurse, and I have worked with nurses my whole career.  I see how they are treated by the system and by patients, and also by us physicians.  And yes, my extracurricular activities focus solely on advocating for physician health and well-being.  Maybe I should learn more about nurse burnout and job satisfaction, and figure out ways to advocate for my nursing friends and colleagues better.

Or maybe it’s too much to ask for groups to stick up for one another.  Maybe Greg is right, and it should be every tribe for itself, let others take care of their own.  Maybe it doesn’t do any good for people to know how and how much doctors “struggle.”  I don’t know.  But I have learned now not to instigate such debates on my friends’ pages on social media.

*Not her real name

 

 

Running Strong In Our Lane

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NaBloPoMo 2018:  What I’m Learning

So the NRA tweets, “Someone should tell self-important anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.”

Hmmm, self-important.  Yes, sometimes.  After four years of college, four years of medical school, up to seven years of residency and then another 3 years of fellowship to earn the privilege of operating on the spines, nerves, organs, and blood vessels of gunshot victims, to maybe give them a chance to stay alive much less walk and talk, I can tolerate a little (just a little) self-importance in my emergency medicine, neurosurgery, trauma surgery, critical care and other colleagues.  They are f*ing rock stars.

Anti-gun.  I have yet to meet any physician, or any person, really, who is wholly anti-gun.  We are pro-gun safety, anti-violence by guns.  We would like for toddlers to not kill their siblings and parents by accident.  We would like for domestic disputes to not escalate to someone shooting their family and then themselves in an impulsive fit of rage.  We would like for depressed and suicidal patients not to actually kill themselves, which is too much easier to do with a firearm than any other method.  We just want to stop being the only country where so many die every year from being shot by guns.

The American College of Physicians (ACP), the internal medicine professional society and my home for professional communion and development, and the largest medical specialty organization, has published an updated position paper on reducing firearm deaths in the US:

In 2015, 9 (the ACP) joined the American College of Surgeons, American College of Obstetricians and Gynecologists, American Public Health Association, American Psychiatric Association, American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, and American Bar Association in a call to action to address gun violence as a public health threat, which was subsequently endorsed by 52 organizations that included clinician organizations, consumer organizations, organizations representing families of gun violence victims, research organizations, public health organizations, and other health advocacy organizations (2). Yet, firearm violence remains a problem—firearm-related mortality rates in the United States are still the highest among high-income countries (3).

Cited in their tweet, the NRA Institute for Legislative Action posted an article (no author identified) picking apart the ACP’s research citations and approach, stating, “This position paper leaves one wondering if the authors reviewed the evidence, or just found works that suited their needs. For all of the bluster about their own important role in the anti-gun movement and all of the misuse of research findings, the ACP makes one thing clear: they respect their own rights and opinions far more than they do those of law-abiding gun owners.”  *sigh*  As I have not read the primary literature on gun mortality and public health myself, I will not comment on that here.  I will just say that I wholeheartedly trust in the integrity of my colleagues and leaders at the ACP.  I’m proud of our advocacy for patients and, more recently, for physicians ourselves and our well-being.

My physician colleagues have posted a multitude of passionate responses on Twitter; you can read them here, here, and here.  And I just now saw this open letter to the NRA from the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) and signed it.  Below are highlights—please take a look.

I admit, I initially responded with profanity at seeing the NRA tweet.  My threshold for swearing is very low these days.  And I wanted to just post screenshots of the anti-NRA tweet storm and let them speak for me.  But that’s not me. I have yet to really decide how I want to design my public platform and conduct on issues like this.  For now, I can just say that tweets and articles like the NRA posted are disappointing.  I don’t want to follow that lead.

* * *

Dear National Rifle Association,

On Wednesday night (11/7/2018), in response to a position paper released by the American College of Physicians (ACP) Reducing Firearm Injuries and Death in the United States, your organization published the statement “Someone should tell self-important anti-gun doctors to stay in their lane.”

On that same day, the CDC published new data indicating that the death toll from gun violence in our nation continues to rise. As we read your demand for us doctors to stay in our lane, we awoke to learn of the 307th mass shooting in 2018 with another 12 innocent lives lost to an entirely preventable cause of death–gun violence.

Every medical professional practicing in the United States has seen enough gun violence firsthand to deeply understand the toll that this public health epidemic is taking on our children, families, and entire communities.

It is long past time for us to acknowledge the epidemic is real, devastating, and has root causes that can be addressed to assuage the damage. We must ALL come together to find meaningful solutions to this very American problem.

We, the undersigned – physicians, nurses, therapists, medical professionals, and other concerned community members – want to tell you that we are absolutely “in our lane” when we propose solutions to prevent death and disability from gun violence.

Our research efforts have been curtailed by your lobbying efforts to Congress. We ask that you join forces with us to find solutions. Help us in our non-partisan, physician-driven research efforts at AFFIRM Research.

We invite you to be part of the solution.

You dismissed the ACP’s position statement on preventing death and injury from gun violence by stating, “Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.”

We extend our invitation for you to collaborate with us to find workable, effective strategies to diminish the death toll from suicide, homicide, domestic violence, and unintentional shootings for the thousands of Americans who will one day find themselves on the wrong side of a barrel of a gun.

We are not anti-gun. We are anti-bullet hole. Let’s work together.

Join us, or move over! This is our lane.

 

Who’s On Your Pit Crew?

 

Who helps you succeed?

Who checks in with you regularly and gives you feedback on your performance?

Who rushes to your side when you need help?

Who can tell not only when you have a lugnut loose but also how to help you tighten it again?

Who is on your pit crew?

I can’t remember the first time I started using this analogy.  I do recall, of course, it came about in a patient encounter.  For a long time now I have consistently asked patients about their emotional support networks, their connections.  As I get older, I feel increasingly aware of and grateful for all the people at every phase of life who have helped me learn, improve, succeed, and become.  Nobody succeeds alone—hell, all but a rare few of us can even survive alone.

My friend Jeremy Topin, a critical care physician, husband, and dad, writes a heartfelt and honest blog about life as all these things—because he is at once all of them and more—there is no way to truly separate one role from another in life.  His recent post on depression among physicians reminded me of the pit crew idea.  Medical culture does not encourage pit crews for its workers.  It’s evolving, painfully slowly, and I hope to have a hand in that evolution.  But for now, far too many physicians and other caregivers suffer burnout, depression, anxiety, and other work-related heaviness in silence, and it can cost us our lives.

Thankfully, many of us have intact and well-functioning pit crews.  46% of physician respondents to the most recent Medscape survey reported talking to friends and family as a coping mechanism, second only to exercise, and right above sleep.  I count my trainer, my therapist, my life coach, and my Counsel of Wisdom, my closest friends, as my core crew.  I have become more and more open about having a therapist and a coach—ya gotta walk the talk if you’re going to be credible about your work.

Full disclosure, I am not a car racing fan.  Pretty much all I know about pit crews is from Disney’s “Cars” and admiring Lightning McQueens’ motley one.  But that’s how it happens, right?  We acquire and accumulate relationships and connections along the winding way in life.  Who knows when or where it might happen?  I met mine in school, in the exam room, at meetings, and I was introduced by mutual acquaintances.

As I consider further, though, having a pit crew is only part of the success story.  Research shows us time and gain that serving on someone else’s pit crew fulfills a profound human need, also.  I suggest works by Adam Grant and Kelly McGonigal if you wish to read more about this.  But maybe you don’t need to read or hear the research evidence to understand this concept?  How does helping others help you?  On whose pit crew do you serve?  To whose Lightning McQueen are you Mater or Luigi?

If your pit crew is sparse, people who study and do this work recommend finding something meaningful or someone you love to serve.  It could be something simple and non-committal, like serving at a soup kitchen or collecting winter coats for shelters.  It could be reading or playing piano at a senior center.  Or it could be mentoring a junior colleague over many months or years.

Imagine a music teacher who accompanies her cello student at recitals.  She plays piano, fingers and hands moving lightly and nimbly over the keys as her protégé plays her heart out during each performance.  I went to my son’s school this afternoon for a music concert, where this pit crew idea struck me again.  I don’t know if the accompanists were the performers’ teachers, but that’s how I saw them, as they were all clearly middle aged adults playing alongside teenagers—surely they had some wisdom to impart in this relationship?  It occurred to me that ‘accompanist’ may not fully accredit these adults’ roles in the kids’ lives.  The music they contributed not only supported the students’ performances.  These adults integrated their music making with the primary performers’, lifting it beyond where it could go alone.  They contributed their own advanced skills and supportive presence to help these young people succeed.  It was a team effort.  And that’s the point, I think.

How widely could we apply this pit crew metaphor?  How does it resonate with you today?  How else is your life like a racecar driver’s?  What’s exhilarating about it?  How is it faster and more intense than other drivers’?  Is that okay with you?  How much longer can you sustain this work, and what do you need to maintain the joy and reward?

Lastly, what did you think of this post?  It’s much more stream of consciousness and impromptu than I’m used to.  I’m trying to get more efficient with my time—three hours per post finishing at 2am on a weeknight is no longer an option.  Your feedback is welcome!

One more weekly post and then the 30 day marathon that is NaBloPoMo, my friends!  Woo hoooooo, ONWARD!

From Meaning to Mission:  Finding Your Voice and Speaking Up for Change

Fairmont workshop room

Have you ever felt like you have no voice in your workplace, your community, or the world at large?  When have you felt you do have a voice?  What made the difference?

Two esteemed colleagues, Liz Lawrence and Eileen Barrett at the University of New Mexico, and I presented the above titled workshop at the International Conference on Physician Health on Friday.  The objective was to give participants an opportunity to recognize and rally their strengths, claim their value and agency, and practice the words to advance an idea or project for improving physician health and well-being.

The idea for the workshop came from a conversation Eileen had with a young physician who felt he had no agency to improve his work situation, due to his junior status.  This prompted her to ask, who has agency, and how do they get it?  She concluded that agency is an active skill, not a passive state of being.  Thus it can be learned/acquired, and everybody has/can have it.  Furthermore, we apply it most effectively when we combine it with our strengths, in service of projects that are personally meaningful.

We presented the reciprocal triad of finding meaning in work, feeling empowered, and inspiration and motivation, as the foundation of agency and action.

EB triad

Identifying Strengths

The first exercise had participants pair up and describe their strengths to each other.

What are your strengths?  Imagine describing them to someone, out loud, in person.  How does this feel?  Our attendees reported feeling uncomfortable, not used to it.  They also felt confident, connected, and encouraged speaking to someone they knew was listening supportively.

Defining the Project

Second, we asked participants to think for a few minutes about their own projects.  It could be something they had been working on for a while, a new idea they recently came across, or something from a sample list we provided, related to Culture of Wellness or Efficiency of Practice.  We asked:

  • Is your idea “Big Enough to Matter, Small Enough to Win?” quoting Jonathan Kozol.
  • Is it Specific, Measurable, Achievable, Relevant, and Time-bound (SMART)?
  • How will your strengths apply?
  • What else do you need? Who can help?

Partners met again to share and discuss each other’s ideas.

Afterward they reported elevated inspiration, excitement, and mutual support.  Positive energy in the room rose palpably at this point, with lots of gesturing, smiling, and engagement.

ICPH 2018 workshop

Communication and Relationship

We didn’t call it an elevator pitch, but that’s basically what we asked attendees to attempt.  In 90 seconds, each participant was to distill and express their idea into words that would convey its essence and enroll their partner in its goal.  Having advanced to this segment of the workshop in less than twenty minutes, and now asking them to perform a pitch on the fly, I gave a pep talk (modified here to include some words I wish I had said):

“Now it’s time to PRACTICE.  If we are to make progress in our projects, we must enroll other people.  It’s all about relationships.  Relationships kill us or save us, and they live and die by communication.  A previous presenter said, ‘Language is the vehicle through which all interactions take place—both verbal and nonverbal.’

“You never know when or where you will meet your champion, or who it will be.  The easier and better you can pull your idea out of your back pocket and present it cogently and impromptu, the higher your chances of success.  Know your ask—be as clear as possible.  Know your audience—what about your project is meaningful to them, what will they relate to?  Make them the hero:  Don’t come at them with demands.  Come alongside them with open-ended questions; help them appreciate the power they have to help.

“You will have to be persistent.  Practice will be key.  Our keynote speaker, applying complexity theory to the work of physician well-being, invoked the image of a grain of sand dropping onto a pile.  One grain may stick on impact and nothing happens to the pile.  Another may cause a small section of sand to tumble just a little.  Yet another grain can trigger the avalanche that alters the sand pile landscape entirely—and no one can predict which grain will be which.  I posit that you are not a grain of sand.  You hold an idea—a whole bag of sand—and each time you pitch it, you drop a grain (or a handful) on the pile.  If one grain makes no immediate change, drop another one, and another, and another.  This is the essence of the Growth Mindset—practice.  Practice is Creation.  Practice is Evolution.  Practice is Progress.  Your job now as speaker is to try with abandon.  There is no such thing as a bad try.  Pay attention to how it feels, where you get stuck, and where you shine.  As the listener, your job is to make it safe for your partner to let go of fear and judgment, to lay it all out.  Support, encourage, and critique with love.  What moved you, what did you observe in words and body language that drew you in or put you off?  What did you want more of?

“Make the most of this time.  Dig in the bag and pull out a few grains to drop.  Take advantage of your partner for feedback and support.”

The room was positively buzzing.  And participants’ comments made our day (paraphrased here):

“Sticking with the same partner throughout was helpful; we could really connect each other’s strengths to our respective ideas and help each other develop them.”

“It was fascinating to see the energy change between talking informally about the idea and then having to present it as a pitch.  She was so much smaller and hesitant the second time around.”  (Partner):  “The first time I was just talking to a colleague.  The second time I pictured presenting to my board.”  The experience was enlightening and curiosity-provoking.

“It’s different and easier talking to a supportive stranger, someone with whom you don’t already have relationship baggage.”  How else, then, might we approach our stakeholders—how could we practice awareness of our assumptions and relationship dynamics, and perhaps modify them positively?

“Hearing someone else’s ideas informs my own.  I like how he conveyed something, I saw how I could do the same; it gave me more insight.”  Taking turns both presenting and listening engaged both people in mutual support and encouragement—both roles were helpful.

The Takeaways

Liz, Eileen and I have collaborated on physician wellness since 2015.  We share meaning and mission around inspiring our colleagues to claim their value, recognize and stand both confidently and humbly in their power, and participate in a global movement of positive change.  Our strengths and styles complement one another and the work flows naturally, synergistically.  What a privilege and an honor it was to have this opportunity to present to and commune with our tribe members in physician health.  May the processing and integration of all of our new learnings continue to sustain and connect us for the long road of work ahead.  As Barack Obama says, “Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change we seek.”

Onward, my friends.

EB LL CC ICPH 2018

Hold One Another Up

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Hello Friends!

How was your week?  I wrote in my last, very brief post that it had been a hard few weeks, but whoa-Nellie, these past 10 days or so have been a bit unbelievable.  But then again, almost nothing is truly unbelievable anymore.

When the news first came out about families getting separated at the border, I felt profound empathy for the parents, and then the kids, imagining their despair, grief, and lasting trauma.  But the administration is now targeting even naturalized citizens, looking for fraud on applications to deport people.  My parents, my husband, and all of his siblings are all naturalized citizens.  My son is currently abroad and it occurred to me to wonder whether he will be held up in customs and immigration on his return.  At this point I cannot know for sure that my own child, a native-born American citizen, won’t be kept from me, and even though it is unlikely, I now feel it fully in the realm of the possible.  I know I’m not the only one.  That is simply unacceptable.

It also occurred to me that any of my Latinx friends and co-workers could be stopped on the street or approached on a bus or train, and commanded to show proof of citizenship, as so many across the country have experienced, illegal and unconstitutional as it may be.  45 actually autographed photos of people who have been killed by illegal immigrants, while denying that native-born citizens commit proportionally more crime than immigrants, legal or illegal.   Right now, June 2018 in the United States, it feels to me that only straight, white, Christian, cisgender males are safe.  It all makes me want to vomit.

In the past year or so, people who know me call me an ‘activist.’  I take immense pride in this perception, and at the same time feel a little unworthy.  What have I done?  In 2017 I wrote a lot of letters to Members of Congress–even had Healing Through Connection stationery printed to do it.  I called.  I donated.  I marched.  2018 has been slower in action.  I’m still reading, keeping up, donating, and engaging on social media.  But I feel like it’s not enough, that I should be doing more.

Today I am more aware than ever that most of my colleagues and institutional leaders are white.  I am East Asian.  We are not the targeted groups.  However empathetic and outraged we may feel, we are likely only indirectly affected by current events.  So many of our support staff, however, are people of color.  They hold positions in the organization with the least autonomy, authority, and voice.

We are all expected come to work every day and do our jobs.  We take care of patients.  We put our personal feelings, stressors, and worries aside and meet our patients where they need us, and nobody knows what we might be dealing with ourselves.  But we do this now during a mind-bending crisis of national conscience.  Now is the time when our emotional and social support networks are called forth and tested.  As a physician, a default leader of the patient care team, how can I not acknowledge this profound disturbance of our collective consciousness?  How can I expect my team to perform optimally in a false vacuum?  The realities of our world are simply inescapable, and they affect us all, like it and accept it or not.

I may not be marching in front of Congress or the DHS.  I may not be writing legislators or calling them every day.  I am not a designated leader of my professional society, publishing op-eds on the long term health and societal consequences of our government’s actions.  But I can absolutely stand up in solidarity with and for the people closest to me.

So this week I expressed to my teams in no uncertain terms that whatever anyone is feeling or going through right now, they should know that their physician leaders support them, and we will be here for them however they need us, just like we are all here for our patients.  I made no overt political commentary.  I simply acknowledged the moral morass I see in our country and tried my best to make it safe for us all to experience it together, out loud and in person, and to help one another through it.

If there were ever a time for physicians to walk the talk as leaders, as caregivers for the caregivers, it is now.  I know now that I don’t have to be the loudest or most visible ‘activist.’  I just have to act in accordance with my core values.  And it starts with holding up the people right next to me every day.