The Only Diet That Works

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Hello Friends!!  Oh my gosh, it feels so good to be writing again, like sinking into my favorite squishy armchair, at the campus coffeehouse where I have met my friends since college, to sip, gab, bond, and plot to save the world.

New phase of life, woo hooooooo!  And eekgadds.  I have long thought of balance as a dynamic state, like that octopus ride at the amusement park.  I am the ride, spinning around, raising and lowering each aspect of life in controlled coordination, attending to each car so nobody flies out and gets hurt.  With the added responsibility I have taken on at work this year, it feels like I have just agreed to accept a massively overweight rider in that car, and my whole frame now strains to keep everything moving smoothly.  At first everything looks normal.  But the continuous strain of gravity, mass, and cumulative sheer forces create microfractures in my arms over time.  And suddenly one day, something (or everything) may come crashing to the ground.  People get hurt.  The ride is broken, in need of major repairs, possibly never the same again.

 

So better to slow the RPMs now, decrease the amplitude of vertical oscillations.  And, increase frequency and intensity of maintenance: inspection, lubrication, computer upgrade, parts replacement.  All of this is to say that 2018 is my year of graduate study in life-octopus ride maintenance.  Curriculum so far includes a lot of Thomas Rhett songs (“Drink a Little Beer”), communion with close friends, and a resurrection of my spiritual life.  I’ got this. [fist bump emoji]

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Okay so, this is a post I have thought about for weeks and I can finally sit down to write it today/tonight.

Since December, two people have told me, essentially, “Medicine has failed at nutrition.”  One person was a good friend, the other a new acquaintance.  Both were athletes, well-educated professionals, and thoughtful men.  I respect both of them and was intrigued by their assertions (and, honestly, just a little defensive).  They pointed to the myriad books, fads, products, news articles, and programs around the country in the last decade or so, all claiming to have the one method for lifelong healthy eating.

Their expressions went something like this:  “What’s the deal with gluten?  I’ve read Wheat Belly and Grain Brain and now I feel conflicted every time I want to have some bread, even though I feel fine, and I like bread.  …Is saturated fat bad or good?  On Atkins I can have as much steak and liver as I want, and my cholesterol is supposed to get better.  And Bulletproof says I should be drinking butter and coconut oil in my coffee.  But my doctors all tell me to minimize red meat and oil in general.  …The Inuit people live off of whale blubber, and they have a fraction of the heart disease we have.  I used to think I knew how to eat healthy and now I’m not so sure.  I’m so confused.”

I was taken aback somewhat by both of these conversations, as I don’t feel confused at all about nutrition and eating.  I feel personally tempted, frustrated, vacillating, under-motivated, and/or fat, depending on the day.  But professionally I feel informed, confident, and reassured that I can counsel my patients solidly toward optimal health.  So wherein lies the disconnect?

In my practice, our approach to nutrition starts with the patient interview.  What is your current eating pattern?  How does weekend or travel eating differ from regular workdays?  How does this pattern either promote or hinder your health and well-being?  What are you doing that’s already healthy and where is there room for improvement?  What needs to happen in order for you to make small, sustainable behavior changes for optimal health?  How important is it to you to do so?  The conversations focus on my patients’ own physical, mental, and emotional experiences around food.  They have a chance to relate their eating habits to personal and professional goals, and a vision for their best selves.

I have learned that my advice needs to be concrete, specific, and relevant at a granular level.  I can roll with Paleo, Atkins, Whole 30, gluten-free, vegetarian, ovo-lacto, oil-less vegan, pescatarian, Mediterranean*, or other diets.  There is some good evidence for all of them.  But is any one of them the sole antidote to all of our eating poisons?  My left brow rises every time I hear someone make this claim.  Here’s the key:  None of these diets tell us to eat pizza, burgers, chips, cheesy fries, dinner rolls, diet soda, craft beer, loaded nachos, fettucine alfredo, cookies, cake, ice cream, and candy the way most of us do.  So what are the underlying origins of my night-time corn chip-cream cheese binges?  What strategies can we brainstorm to cut back on my birthday cake consumption between birthdays?  Questions like these and the conversations that follow serve my patients far better than my recommending the blood type diet (which I do not).

Furthermore, leading proponents of each of these diets also emphasize the importance of concurrent self-care in the other realms of health: Exercise, Sleep, Stress Management, and Relationships.  Diet and nutrition are vitally important for health, but they do not occur in a vacuum.  All of our health behaviors need to be assessed in their combined context, and recommendations are best made with circumstances, preferences, logistics, and access in mind.

If you’re an elite athlete whose diet is already 99% cleaner than the rest of us, yes, maybe there is a subtle difference between medical diets that will affect your performance and sports longevity.  Then again, maybe not.  And you are also likely attending to your needs for training, rest, recovery, and stress management.  So you’re probably good either way.

For us regular people, the only diet that works is the one we can stick to, that doesn’t cost us inordinate amounts of psychic energy to maintain, and that actually makes us healthier.  How can we tell we’re healthier?  We may feel: lighter on our feet, increased energy, more regular bowel movements, clearer skin.  When we see our doctors (as we all should, ahem) they may find we have lower blood pressure, lower body fat, smaller waist circumference, lower fasting and overall glucose, lower LDL and triglycerides, and an overall brighter aura and vibe.

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So maybe keep Michael Pollan’s words in mind as a general guideline: “Eat food.  Not too much.  Mostly plants.”  I would add:  Eat foods as close to how they occur in nature as possible.  If you can tell what leaf/seed/grain it is by looking at it, it’s probably better than if you cannot.  Harvest/kill it, cook it (or not), eat it.  The fewer steps the better.  Eat often and slowly with people you love.  Help each other moderate the junk.  Enjoy your food.  Life is short.  Strive for an eating life that adds joy and delight to your whole being, both immediately and in the long term.

Onward, my friends.

 

*I have no financial, philosophical, or other interests in any of these or other diet programs, products, centers, providers, etc.

200th Post: The Best of Healing Through Connection

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Happy New Year, my friends!  May 2018 bring us all health, joy, connection, and learning!  And may we all look back one year from now feeling more empathy and compassion, and enjoying better relationships than ever before.

If you are new to this blog, welcome!  I hope you find something that resonates.  If you are an old friend, thank you for your support, feedback, and encouragement the last 32 months.  As I reread the last 199 posts this past week, my favorite parts were the thoughtful and enlightening comments.  I never imagined I could make friends writing a blog and yet here we are, connected, engaged, and holding one another up.

What have you discovered about your own writing when you go back and read?  Turns out I have a pretty consistent theme—it’s all about relationships.  Relationships require awareness, insight, active engagement, negotiation, and adaptation.  This is no less true in our relationships with ourselves than with others.  I have divided my favorite posts below into three categories: Health & Self-Care, Physician-Patient Relationship, and Relationships and Communication in general.  Though I have written pieces on politics and healthcare, I realize that these are critical arenas in which to explore relationships, and not my primary areas of focus in and of themselves.

2018 brings big new projects and responsibilities, yay!  So of course there will be big new challenges, also yay!  Looking ahead, I commit to my self-care practices with renewed motivation:

  1. Get to bed by 11:30 every night—Coach Christine has permission to call me out if I’m caught Facebooking past this time.
  2. Maintain 4+ workouts per week. An aging body needs regular vigorous movement!
  3. Keep up with therapy and resume regular coaching calls—reflect internally and project my best self outwardly.
  4. Maximize intake of stems, stalks, leaves, and fruit; minimize refined sugars.
  5. Nurture my ties to my tribes. They hold me up so I can do my best for those whom I lead.

The coming year will also require pulling back on certain things in order to maintain sanity.  While I refuse to renounce my Facebook use altogether, I have already decreased daily hours spent.  And though I still strive to maintain social/political awareness and activism, I will engage less with opposing voices on social media.  The costs, I have learned, far outweigh the benefits.  I would much rather take a politically oppositional friend out to lunch, or even fly to meet them, and have far more meaningful conversations in person.

For now, I plan also to scale back on the blog.  I’ll continue to write, of course, but likely more in the form of stream-of-consciousness journaling, brain-dumping, and snail mail letters to friends.  I expect that once in a while one of these activities will yield a post or two, and I hope to catch them by the tail and publish them before they escape the moment.  I leave here the list of my favorite posts to date.  Please feel free to dip in and out, leave new comments, and share links.  I suspect I will be drawn back to the page before long, as I already have a list of ideas for future posts.  But in case it’s longer than I anticipate, please know that I appreciate every view, every like, every comment, and every connection.

Thank you for stopping by and taking the time to read.  And may you take something away that makes you glad you came.

Sincerely,

Cathy Cheng


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Health and Self-Care

The Sh*tpile  /May 2015

https://catherinechengmd.com/2015/05/01/the-shtpile/

Everybody has one.  We inherit large parts of it from our parents, whose parents passed theirs down, etc.  Life experiences add mass and odor as we grow up.  It sits squarely in the middle of the house of our existence.  For the most part, we simply live our lives around it, walking past every day, careful not to knock any pieces off.  The surface gets dry and crusty; we grow accustomed to the smell.

 

How Health Begets Health  /November 2015

https://catherinechengmd.com/2015/11/07/how-health-begets-health/

As the kids and I sat waiting to get their flu vaccines this morning, I heard someone blow their nose. It was that thick mucus blowing that feels, at the same time, both gross and gratifying. I took a deep breath through my unobstructed nostrils and looked happily at my uninfected children.

 

Setting Intensions for 2016  /January 2016

https://catherinechengmd.com/2016/01/01/setting-intentions-for-2016/

This year I realized my body’s inevitable march toward menopause, a stark and sudden awareness. It came to me sometime in the spring, and I felt a keen jolt of motivation to prepare.   After 13 years of practice, I recognize two characteristics of women who suffer the least through this dramatic hormonal transition.

 

So You Want to Lose Weight  /March 2016

https://catherinechengmd.com/2016/03/12/so-you-want-to-lose-weight-the-four-as-of-goal-setting/

We set weight loss goals all the time, all of us—physicians included. We choose a number on the scale—an outcome—that represents our better selves, however we see it.  I suggest today that behavior-oriented goals, rather than outcomes-oriented ones, lead to far greater and more meaningful success.  How much are we really in control of what we weigh, day to day?

 

Never and Now  /April 2016

https://catherinechengmd.com/2016/04/17/atozchallenge-never-and-now/

And, there is another important practice to overcoming the Nevers: Mindfulness, the practice of the Now.  Never is about the future or the past.  Often it’s a shadowy, catastrophizing perspective of things.  But we cannot predict the future, despite our arrogant human certainty.  And we cannot live every day to come based solely on what has already happened or not happened.  Circumstances and attitudes change.  Landscapes change—at times literally, and in an instant.  We evolve, we learn, we grow.  How can we be so sure that Never is real?

 

Yes, And!  /April 2016

https://catherinechengmd.com/2016/04/30/atozchallenge-yes-and/

The goal is to open our minds, allow possibilities, expand our boundaries, and encourage creativity. I can still see her smile, the gleaming light of engagement and anticipation in her eyes.  I also remember my own hesitation and self-consciousness.  What do you mean, pimple on my forehead?  Is it really about to burst?

 

On the Critical Importance of Self-Care  /November 2016

https://catherinechengmd.com/2016/11/06/1638/

Technology and other advances have created a world of 24/7 hyper-stimulation, global comparisons of productivity and innovation, and immense pressures to be perfect, or at least appear so.  Men and women live under constant scrutiny and competition… I see, hear, and feel it from my patients every day—the anxiety, the uncertainty, the angst.  The suffering is real, if not totally tangible.

 

On the Second Arrow  /November 2016

https://catherinechengmd.com/2016/11/11/on-the-second-arrow/

Eventually, breathing, we can let go the negativity, pull the arrow out.  Breathe.  When assailed by another first arrow, see the second arrow coming and sidestep.  Breathe.  Keep breathing.  Practice self-compassion and forgiveness.

 

On Readiness  /November 2016

https://catherinechengmd.com/2016/11/16/on-readiness/

I confess I am guilty of impatience and judgment.  When I see your uncontrolled, lifestyle-related medical problems, and you resist behavior change, I feel frustrated.  I know you feel it, too.  But know that I don’t blame you. The point is: we don’t make changes until we are ready.

 

Walking the Talk  /July 2017

https://catherinechengmd.com/2017/07/09/walking-the-talk/

18 months ago I wrote about my plan for maximizing menopause preparedness.  As with so many missions, this one has experienced both successes and failures.

 

Just Do It My Butt  /November 2017

https://catherinechengmd.com/2017/11/06/just-do-it-my-butt/

Medical systems which include dieticians, exercise physiologists, and health psychologists can deploy these team members to support patients in their health journeys.  But does your doctor’s office have this kind of set up?  Does your insurance pay for these services?

 

Citius, Altius, Fortius!  /November 2015

https://catherinechengmd.com/2015/11/09/citius-altius-fortius/

Every day I live in awe of the astounding miracle that is the human body. It is the quintessential integrated machine.   Almost every part serves a unique and essential purpose in normal daily function, and the parameters for such function are incredibly narrow.  But take something out, wound something else, or trash multiple systems at once, and the whole assembly adapts around the insults, automatically, without any action or awareness on our part.  The body’s compensatory mechanisms exemplify the resilience and tenacity of nature, no doubt about it.

 

Dance For Your Health  /November 2017

https://catherinechengmd.com/2017/11/16/dance-for-your-health/

So basically, dancing activates key areas of the brain and body in an orchestrated fashion, igniting motion, joy, connection, exhilaration, sensory integration, creativity, passion, cardiovascular elasticity, and fun.  How could this not make us all younger?


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Physician-Patient Relationship

The Premise  /April 2015

https://catherinechengmd.com/2015/04/14/hello-world/

Patients and physicians have control over one thing above all else: our relationship with each other.  Relationships live and die by communication.  Barriers on the obstacle course of patient-physician communication loom large and formidable. Our system fails us over and again. And it falls to each of us, not the system, to find our way to connection and healing relationships.

 

What Are You Looking For?  /April 2015

https://catherinechengmd.com/2015/04/22/what-are-you-looking-for/

My mind’s eye saw hers widen with disappointment, then anger, her posture turn aggressive.  My inner conflict escalated quickly:  Sacrifice the rapport I had just established in the name of antibiotic stewardship, or give in to the misguided pleas of a wrung out fellow working mom, and contribute personally to the scourge of antibiotic overuse and resistance?

 

More Than Enough Love  /June 2015

https://catherinechengmd.com/2015/06/20/more-than-enough-love/

Like parenting, the path of medical practice is not paved with lollipops and ice cream.  It’s more like an uphill dirt road with pits and grooves, erratic weather, and hairpin turns that make you dizzy and nauseated.  It can also offer astoundingly beautiful scenery along the way—like parenting.

 

Help Me Help You  /July 2015

https://catherinechengmd.com/2015/07/10/help-me-help-you/

When you feel that disconnect, like I have left Best Me somewhere else and you’re not getting what you need, what will you do?  Will you yell and storm away? Smile to my face and then write a scathing, anonymous Yelp review? What would you do if I were your spouse, colleague, friend, or child? You and I are in a relationship, not unlike these.

 

Closing the Satisfaction Gap  /July 2015

https://catherinechengmd.com/2015/07/20/the-thorn-in-our-collective-side/

This patient gave Dr. K the best possible feedback: An objective observation about a behavior, her subjective interpretation of it, and its consequence for their relationship.  This is how we communicate evaluations to medical students on their performance in clinical rotations.  There is no reason why it should stop at the end of training; it’s just that the evaluators have changed.

 

The Burnout Crucible  /September 2015

https://catherinechengmd.com/2015/09/20/the-burnout-crucible/

Maybe it’s a moot point, whether it’s better to never burn out or to burn out and relight. We’re all here doing our best every day. Maybe it’s more important to just cut ourselves and one another a little slack sometimes, have compassion for aggressors while calling out their unjust behaviors, and offer everybody the benefit of the doubt, especially when we’re all stressed out.

 

What Makes You Think You Can Trust Me?  /February 2016

https://catherinechengmd.com/2016/02/01/what-makes-you-think-you-can-trust-me/

Trust is the cornerstone of any meaningful relationship. The patient-physician relationship is no exception. It takes time and presence to cultivate. These are big investments, and if we are willing to make them, the returns can literally save us.

 

 

I am Edna Mode  /February 2016

https://catherinechengmd.com/2016/02/20/i-am-edna-mode/

Clearly, Edna trained in the School of Tough Love.  Fortunately for you, I have also studied empathy, compassion, and motivational interviewing.  I can help you persist.  I have patience for your journey.  I can be your pillar of consistency.  Edna is nothing if not consistent!

 

Humbling and Honoring  /April 2016

https://catherinechengmd.com/2016/04/09/humbling-and-honoring/

I get to choose when I am willing to donate my time and energy to the free clinic—everything I do there is on my own terms.  The patients there have no such choices.  If they want care, they have to show up—early—on the day the clinic is open, regardless of what else is going on in their lives.  There are no appointments, and almost no continuity with providers.  It’s a completely different world from where I make my living, on the Gold Coast of Chicago.

 

On Mutual Respect  /November 2016

https://catherinechengmd.com/2016/11/05/on-mutual-respect/

To Patients Who Abuse Medical Staff: Let me be clear: That is not okay.

 

No Substitute for Time  /November 2017

https://catherinechengmd.com/2017/11/03/no-substitute-for-time/

“More information about the value of a physician-patient encounter will always be found in the content of their communication than in what they ultimately do. The difference in… physicians’ behaviors will not be found in any database, electronic medical record, or machine-learning algorithm. I have yet to see data on the contextual information from a history of the present illness in any data set or quality improvement initiative.”

 

Dr. Jerkface In Context: Healing the physician-patient relationship  /November 2017

https://catherinechengmd.com/2017/11/25/dr-jerkface-in-context-healing-the-patient-physician-relationship/

Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.


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Relationships and Communication

Gratitude, Generosity, and Peace  /July 2015

https://catherinechengmd.com/2015/07/30/gratitude-and-generosity/

When I feel grateful, there is enough. I am enough. Even just saying the word, seeing it on the screen, brings me to a more peaceful state of mind and body.

 

Warrior Pride and a Plea for Kindness  /December 2015

https://catherinechengmd.com/2015/12/13/warrior-pride-and-a-plea-for-kindness/

There is no substitute for a face-to-face conversation, and the time and energy it takes to have one. It requires a certain degree of tolerance, and an unspoken contract of civility and courtesy.  We must choose carefully with whom we are willing to undertake such a venture.  And perhaps most importantly, we must be clear about our objective(s).  Do we really expect to change someone’s fundamentally held political or religious beliefs?  How realistic is that?  What other purpose, what other good, could possibly come from such conversations?

 

On Belay  /April 2016

https://catherinechengmd.com/2016/04/02/on-belay/

The interview starts with the two men talking about Hank Williams’ troubled life, his ‘formidable demons,’ as Hiddleston puts it. He expresses compassion for this, as I have seen him do in previous interviews about other characters he has portrayed.  He describes how Williams rose to stardom quickly, but ‘with no real support, no one to anchor him.’  Funny how he uses that word, anchor—like belayer.

 

Opposition and Openness  /April 2016

https://catherinechengmd.com/2016/04/20/atozchallenge-opposition-and-openness/

When I look at the list of definitions of oppose, I feel tired.  When I think of the energy it takes to constantly stand against something, I feel listless and drained.  Fighting, resisting, combatting, Obstructing, standing in the way, hindering, disputing, dissenting, contradicting—it’s exhausting.  I think of times when I meet someone new and all they talk about are the things they hate, that they can’t stand, that they want changed.  I cannot wait to get away and find levity.

 

Every Day a Revolution  /April 2016

https://catherinechengmd.com/2016/04/22/atozchallenge-every-day-a-revolution/

Like the turning of an incandescent light bulb, gently, patiently, and consistently in one direction, the steady work of activists eventually leads to sudden and intense illumination.  Darkness becomes light, cold spaces are warmed.

 

Withhold Judgment  /April 2016

https://catherinechengmd.com/2016/04/29/atozchallenge-withhold-judgment/

After all of this exploration, conversation, debate, research, and observation, once again I conclude that one of the most important practices for inner peace is to Withhold Judgment. Not all judgment, and not indefinitely, but much and for a while.

 

Playing My Part  /May 2016

https://catherinechengmd.com/2016/05/22/playing-my-part/

Given the awesome support network with which I am blessed, I feel an impulse to do something more with my writing—to amplify and project all this love and connection back out onto the world for some positive purpose.  But how can my words possibly make a difference?

 

Holding the Space for Personal Acts of Peace—On Listening  /July 2016

https://catherinechengmd.com/2016/07/11/holding-the-space-for-personal-acts-of-peace-listening/

I know I will not do justice to all the complexities of our issues in one blog post, but I ask your forbearance for my interpretation, as it has led me to greater conviction for what I can do, I, one person.

 

Holding the Space for Our Suffering to Heal Us  /September 2016

https://catherinechengmd.com/2016/09/22/holding-the-space-for-our-suffering-to-heal-us/

For a moment we felt stuck, we connection seekers.  I looked at our leader.  His expression conveyed nothing but humility and empathy.  His posture conveyed resolution.  Despite our deep longing, he refused to lead us into treacherously thorny fields, because he knew he did not have the time to bring us safely through to the other side.  But he also allowed us to process, invited us to consider how else we could collectively resolve our unease.

 

On the Golden Positivity Ratio  /November 2016

https://catherinechengmd.com/2016/11/25/on-the-golden-positivity-ratio/

I remembered something about healthy relationships maintaining a 3:1 ratio of positive to negative interactions.  Turns out it’s actually 5:1, widely attributed to observations by Dr. John Gottman, renowned marriage and relationship psychologist.  I think the same thing applies in other realms, too, such as self-talk—a reflection of our relationships with ourselves.  It’s not a far leap to see how this idea pertains to news, social media, and any other human interactions.

 

Train to Withstand the Discomfort  /February 2017

https://catherinechengmd.com/2017/02/20/train-to-withstand-the-discomfort/

We all know the satisfaction and comfort of echo chambers.  Seeing, hearing, and reading that which validates our existing positions feels so good.  But the farther we regress here, the harder it becomes to tolerate a dissenting view.  We must resist this temptation; we are called to be more disciplined than this.

 

To Train or Not to Train  /May 2017

https://catherinechengmd.com/2017/05/08/to-train-or-not-to-train/

…even if we don’t all talk politics, we all need effective communication skills, especially in the arenas of conflict resolution, negotiation, parenting (which encompasses them all), and the like.  We are social beings—we only survive by cooperating and living well within our tribes, and by tribes living well among one another.  That can only happen if we practice getting along.

 

Tribal Pride and Tribalism  /November 2017

https://catherinechengmd.com/2017/11/29/tribal-pride-and-tribalism/

We all need our tribes.  Belonging is an essential human need. To fit in, feel understood and accepted, secure—these are necessary for whole person health.  And when our tribes have purpose beyond survival, provide meaning greater than simple self-preservation, our membership feels that much more valuable to us.  But what happens when tribes pit themselves against one another?  How are we all harmed when we veer from “We’re great!” toward “They suck”?

 

 

 

Tribal Pride and Tribalism

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NaBloPoMo 2017: Field Notes from a Life in Medicine

What tribes do you belong to?  How do they serve you, and you them?  How not?

I think of this today as I have traveled out of state to speak to a Department of Surgery on physician well-being.  I wonder how often they have internists present at their Grand Rounds?  What a tremendous honor, I’m so excited to be here!  I hope my talk will be useful and memorable, as I represent my field and my institution, in addition to myself.  In the talk I describe the central tenets of Tribal Leadership and culture, and how to elevate ours in medicine.

So I’m thinking tonight about tribal pride and tribalism—the benefits and risks of belonging.

We all need our tribes.  Belonging is an essential human need. To fit in, feel understood and accepted, secure—these are necessary for whole person health.  And when our tribes have purpose beyond survival, provide meaning greater than simple self-preservation, our membership feels that much more valuable to us.  But what happens when tribes pit themselves against one another?  How are we all harmed when we veer from “We’re great!” toward “They suck”?

Of course I’m thinking now of intra-professional tribalism:  Surgery vs. Medicine vs. Anesthesia vs. OB/gyne vs. Psychiatry.  Each specialty has its culture and priorities, strengths and focus.  Ask any of us in public and we will extol each other’s virtues and profess how we are all needed and equally valuable.  Behind closed doors, though, internists will call orthopods dumb carpenters; surgeons describe internists’ stethoscopes as flea collars, and the list of pejoratives goes on.  Maybe I’m too cynical?  My interactions with colleagues in other fields are usually very professional and friendly—until they are not.  I have experienced condescension and outright hostility before.  But can I attribute it to tribalism—that general, abstracted “I’m better than you because of what I do” attitude—or to individual assholery?  Or maybe those docs are just burned out?  As with most things, it’s probably a combination.  Based on what my medical students tell me, negative energy between specialties definitely thrives in some corners of our profession.  Third year medical students are like foster children rotating between dysfunctional homes of the same extended family—hearing from each why all the others suck.

So what can we do about this?  Should we actively police people’s thoughts and words in their private moments?  I mean part of feeling “We’re Great!” kind of involves comparing ourselves with others and feeling better than, right?  Isn’t some level of competition good for driving innovation and excellence?  Should we even embrace this aspect of tribal pride?  It certainly does not appear to be diminishing, and I have a feeling it’s just human nature, so probably futile to fight it.

I wonder why we have this need to feel better than.  Is it fear?  A sense of scarcity?  As if there is not enough recognition to go around?  Like the pie of appreciation is finite, and if you get more I necessarily get less?  Intellectually we recognize that we are all needed, we all contribute.  But emotionally somehow we still feel this need to put down, have power over, stand in front.  And it’s not just in medicine.  I see it in men vs. women, doctors vs. nurses, liberals vs. conservatives, and between racial and ethnic groups.  It makes me tired.

But maybe we can manage it better.  Maybe we can be more open and honest about our tribal tensions, bring them into the light.  Yes, I think surgeons can be arrogant.  And that’s okay to a certain extent—it takes a certain level of egotism to cut into people, and when things start going wrong in the OR, I think that trait can help make surgeons decisive and appropriately commanding when necessary.  I imagine surgeons get impatient with all the talking we internists engage in.  So many words, so little action, they might think.  And yet they understand that words are how we communicate with patients, how we foster understanding and trust.  Maybe we can all do a better job of acknowledging one another’s strengths and contributions out loud and in front of our peers (and learners).  The more we say and hear such things, the more we internalize the ideals.

Tomorrow I get to spend a morning with surgical attendings and residents.  I hope to contribute to their learning during my hour long presentation, but I really look forward to my own learning, to expanding my understanding and exposure to parts of my profession that I don’t normally see.  I’m humbled at the opportunity, and I will look for more chances to bring together colleagues from divergent fields.  If we commit, we can connect our tribes and form a more cohesive profession.  That is my dream for future generations of doctors—to be freed from infighting and empowered to collaborate at the highest levels, for the benefit of us all.

 

Ode to My Dawn Simulator

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NaBloPoMo 2017: Field Notes from a Life in Medicine

Did you notice the photo on my post Gratitude Again?  That was the view out my office window around 5:30pm last week.  These days I appreciate the winter dusk a lot more than years past, mostly because the physically hardest years of training and my kids’ lives (for me) are over.  My intern year I rotated in the medical intensive care unit (MICU, or MICK-you, or just ‘the unit’ for short) in November.  Usual days started by 6am, and finished whenever my patients were stable enough for me to leave, usually past 7pm.  I really never saw the sun that whole month—not from outside, anyway.  Every third night on call, my resident and I covered the whole place.  The longest I ever spent in the hospital was 5am until 10pm the following night—41 hours straight, only to be back again the next morning at 6.  And that was nothing compared to the generation of doctors who trained before me.  Thinking back on it now, I can still feel the saturating fatigue, the utter hopelessness of ever seeing the call room, let alone lying down on a bed.  Thank GOD those days are over.  They weren’t all bad, though.  Residency was one of the hardest things I’ve done, and it was also intensely rewarding.  The friendships I made those years, the unique shared experiences—I carry these with me also.  They made me strong and gave me confidence.

But if I thought getting up in the dark during intern year was hard, somehow doing it as an attending with two little kids was even harder—go figure.  The sleep deprivation of working motherhood is a completely different animal from that of residency, its toll multiplied on family.  The blaring alarm clock, the utter blackness of the bedroom, the contrast of cozy warmth under the blankets with the cold still air above.  They all conspired to make me peevish, sullen, and supremely unpleasant to be around every morning—an additional cost to my soul every time I lashed out at the kiddos out of my own exhaustion.  To borrow a phrase from Vee over at Cute Kids, I might well have died of a bad mood or something worse if that situation continued.

So Husband staged an intervention: He bought me a dawn simulator for Christmas.  It’s an ingeniously simple device: An alarm clock with a built-in light dimmer that comes with its own full-spectrum light bulb.  All you have to do is connect it to a bedside lamp.  Then you set sunrise time, as well as duration of rise (I set mine to 6:45, 15 minutes).  Every morning for the past 7 years I wake up naturally from a steadily brightening, gentle and warm glow from one corner of the room.  It’s infinitely more pleasing; no blaring involved.  Of course now I have my iPhone ‘by the seaside’ alarm as back up, especially for this month as I stay up too late writing blog posts.  And I’m not a morning person in general, so no Mary Poppins songs bursting forth with domesticated mechanical birds on my windowsill.  But life is infinitely more tolerable between Halloween and Easter each year now—for all of us.

Thanks, Husband.  Ya done good.

Dr. Jerkface In Context—Healing the Patient-Physician Relationship

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Excuse me, I took an unintended break for Thanksgiving!  Hope you all had a wonderful holiday!

NaBloPoMo 2017: Field Notes from a Life in Medicine

For the past year or so, maybe more, I have increasingly tried to engage my friends in discussion around allied advocacy for physician health and well-being.  Inevitably, however, I’m met with anecdotes from my friends about asshole doctors.  It is a strikingly common experience, I’m sad to report.  And it makes sense:  If a patient has a bad experience with a doctor, ie the doctor behaves badly or the patient feels dismissed, ignored, disrespected, or mistreated, the normal response is to blame the doctor and assume that s/he is an asshole.  In each of these interviews with friends, it took a while for them to come around to the idea that the doctor him/herself may be suffering and therefore not behaving/performing their best.

But the next question is this: Do patients care about doctors’ suffering?  If they knew how the system harms physicians, would they have compassion for us?  What about if they knew how physician burnout and dissatisfaction directly affects their quality of care, all of it negatively?  What would move patients to stand up with and for doctors?  This is my goal for the indefinite future: to help us, patients and physicians, the end users of our medical system, stand up with and for one another, for positive systems change.

Right now I see it as a very personal, grassroots endeavor.  Outside of a one-on-one patient-physician relationship, ‘patients’ and ‘physicians’ in general are abstract groups to us all, and it’s hard to feel compassion for and connection with an abstraction.  “Patients are too demanding, entitled, and ignorant.”  “Doctors are arrogant, dismissive, and profit-driven.”  We carry these overgeneralized internal narratives and others into our encounters, often unknowingly and unintentionally.  Even when we think we see and know the person right in front of us, these underlying assumptions still color our experiences with them.  So whatever conversations we may undertake will take many repetitions to finally reach true mutual understanding.

I have been a member of my church since 1991.  Many others in the community have been there much longer than that.  There are other physicians, and we are all patients, ranging in age from infants to octogenarians.  I have proposed to host a focus group to discuss patient-physician relationship, especially as it relates to the effects of physician burnout on patient care.  The plan is to do it once, with whomever is interested, and see what happens after that.  I picture 10-20 people, patients and physicians alike, seated in a circle.

The objectives will be stated:

  1. Hold an open discussion about people’s experiences in the patient-physician encounter, and explore the context of forces that influence those experiences. Such forces include visit duration, documentation requirements, workflow inefficiencies, patient expectations, insurance status, and clinical setting (hospital, outpatient clinic, etc.).
  2. Participants leave with improved mutual understanding of one another’s experiences in the medical system and more likely to feel empathy and compassion toward their counterparts in the next encounter.

In the long term, I wish for patients and physicians to form a unified platform from which to advocate for policy change.  We, patients and physicians, are the end-users of the healthcare system, the largest combined demographic in the system, and I believe we are the ones who benefit the least from the system.  Health outcomes for American patients are dismal compared other developed countries, despite our exorbitant expernditures.  Physicians kill ourselves at more than twice the rate of the general population.

It’s not enough for medical professional societies to write co-authored, open letters to Congress.  It’s not enough for individual patient constituents to stand up at town halls and berate their representatives.  We must orient ourselves as resistors in series, rather than in parallel.  I think the movement will grow most effectively out of existing connections and relationships, through which we can find shared interests, common goals, and a strong, unified voice for change.

I seek your feedback:

  1. How do you picture this meeting going?
  2. How interested are you in learning about physician burnout and how it affects patients?
  3. If you were invited to such a meeting, what would you think and feel about it?
  4. What would make you more likely to participate?
  5. Would you want to host such a meeting in your community? How would you do it?

Thank you for considering, and see you tomorrow!

Incomplete Thoughts on Suicide

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Not selfish

Not thoughtless

Simply belief beyond shadow that no one will mourn you, people will be better off without you

Unimaginable for those who have not lived it

Most who try once don’t try again

So better to keep guns away

——————–

One of my high school classmates killed himself when we were seniors.  He shot himself in the head at home.  He was the vice president of our Students Against Driving Drunk chapter (I was president).  He was a member of the National Honor Society.  He was well-liked, always friendly, generous, smiling, encouraging.  He was a nerd, and so was I, so I thought nothing of it.  I did not know him well, and I never asked him about his life, that I recall.  I have no idea whether he was bullied or what drove him to take his own life.

The morning we found out, our calculus teacher had to sit down in the middle of the lesson. She was overcome.  One of my other classmates got up and hugged her.  She had more presence of mind than I.  I can’t remember if it was that moment or later, or if it was our teacher or someone else altogether, who said something like suicide is ultimately a selfish act.  That it was inconsistent with our classmate’s character to cause so many people so much pain.  That if he had known how much he would hurt people by this act, he never would have done it.  I can’t say I had thought anything about suicide before then, and I have probably not thought enough about it since, but her words stuck with me.  I’m not sure I would have ever come to this conclusion.

The way I understand (think I understand) it today, suicidality is such dark state, a place so far removed from where we connect with our true selves and others, including (especially?) loved ones, that people really do believe that everybody else will be better off without them, that there is nothing worth living for.  I cannot fathom that kind of disconnection and loneliness.  It feels almost too scary to even contemplate.  I feel totally incompetent to address this kind of pain and suffering.

I saw this video recently and it moved me.  A young man jumped off the Golden Gate Bridge and survived; he tells his story of instant regret for the attempt, and gratitude to be alive.

I pray tonight that if anyone in my circle is feeling suicidal, I may say or do something to help them know they are loved, wanted, and connected, and to keep them with us long enough to get help.

 

I’m the Doctor, You’re the Doctor

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NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.