What I’m Learning About Equity

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My friends, I am humbled this weekend.

A year ago I agreed to present on culture change to the inaugural WEL cohort, a group of 18 amazing women physician leaders.  I had no idea at the time what an honor and privilege this would be.  This would be the last in person meeting of their 18 month training on Wellness, Equity, and Leadership.  Having just completed my own 10 month leadership training, I empathized acutely with the bittersweet bonding and pending farewell among these sisters.

For two days I received infinitely more than I offered, and I saw again how membership in a mutually respectful, supportive, and empowering tribe can transform any individual from star to superstar.  Truly, these women were superstars before this tribe was formed; but whereas before we probably only needed dark sunglasses in their presence, now we need welder’s masks.

Gender, race, socioeconomic status, mental health status—these factors among others are all subject to unconscious bias and thus discrimination, in all arenas of society.  These WEL women will have a hand in changing that for the better, of this I am certain.  I’m so proud to know them all.

The night before my presentation, I messaged my friend who has helped me think more deeply about these issues in the past year.  I wrote, “It reminds me of your idea of approaching inclusion first, which I now see as wide psychological safety.  As you said, there can be a room full of white men and all may not feel included. And in my mind, that precludes true, open and honest collaboration and productivity.  It prevents any forward movement toward diversity or equity. When we don’t feel safe we revert to scarcity and survival thinking.  We look out only for ourselves.  Nothing good happens here.”

What about the one Old White Guy (OWG) among women, how does he feel?  Dr. Clif Knight, Senior Vice President of Education for the American Academy of Family Physicans and WEL steering committee member, owned this distinction this week.  He reported his recent self-identification as ‘a HeForShe.’  My heart leapt for joy.  Later I took him by the lapels and shook him (gently), practically yelling that I was so excited, and wished for him to recruit all of his OWG friends to the cause.

I thought again about my friend above, also an OWG.  I know him to be kind, generous, respectful of women and a genuine ally.  What about his idea of working on inclusion first?  After a long, deep conversation with one of my new WEL friends, with whom I’m also thinking about equity issues for Asian-American physicians, a new insight dawned on me, and I wrote to her: “Practicing inclusion INCLUDES the OWG ‘oppressor’! 😱  If we talk only about him needing to include others, while we make him feel excluded himself, how can we ever expect to enroll him in our cause or even behave in the way we ask? We do how we feel. And when we feel threatened and marginalized, especially from a place of loss, we act accordingly…”

Another new WEL friend, Dr. Dawn Sears, has already taken this idea to heart and made an impact in her community, elevating women’s and men’s awareness of gender disparity in medicine, and helping them fight it together.  Check out her powerful presentation to colleagues here, full of evidence as well as unsettling personal stories.  In it she directly and kindly addresses the men in the audience, informing and inviting them to join the fight, for all our sakes.  She names the contrarian men who have held her up on her professional journey, defying gender bias and paving their own HeForShe way for others.  She includes men in order to enroll them in the movement.  I encourage all to view the talk—find out how you, as colleague, patient, and all around good citizen, man or woman, can help improve the system for us all.

Once again I thought about my friend.  I wrote to him again:  “I wonder if I inadvertently made you feel excluded, or at least ‘other’d’ when I asked you to read Feminist Fight Club*.  DUH, the intended audience for that book is women.”  He was gracious and encouraging in his response, and I look forward to continuing our conversation for a long while.

Tonight I feel wildly optimistic.  So many strong, visible, articulate, creative, powerful and loving people all over the place, all working to make the world better for all of us, WOW.  We will make a difference, my friends.  We are not only allies; we are accomplices.  If we go together, we can do anything.

Onward, friends.  We’ got lots to do.

 

*He made an earnest, good faith effort, and did not finish the book.

All Good Things Must End

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Setting moon, Sylvan Dale Guest Ranch, Loveland, Colorado.  Photo courtesy of Dr. Karen Cornell

Friends, Leading Organizations to Health has graduated Cohort 11, the Class of 2020.

Ten months ago I started at my Hogwarts, the leadership training program that has definitely made me a better leader.  But more importantly, it made me nine amazing new friends and a much better person.  Today, on the last day of the last retreat, it all came together in the most beautiful way, and I am beyond grateful.

These ten months were the best elective educational experience of my life—they really gave college and med school a run for their money.  We immersed in a curriculum dense with abstract concepts of interpersonal communication and organizational change management.  We then translated the theories into tangible skills in an experiential learning lab, applied to specific challenges brought by my 7 cohort mates and me.  Over four in-person retreats and monthly Zoom calls, we shared, supported, and coached one another in the tenets of relationship-centered leadership.

We bonded in a similar way to residents on call:  Gathered for training, bringing different backgrounds and perspectives, participating in a common curriculum but each with a unique learning path, eventually to disperse and practice in different settings across the country.  We eight now share a connection of stories and struggle that nobody else can know.  We are a tribe.

Thus, I grieved the goodbyes long before we arrived in Loveland this last time.  But I also trusted our master facilitators to help me manage this, by both their loving and authentic presence and the very structure of the program, which is founded on contemplation and self-awareness.  I also felt an abiding faith in the friendships we all grew this past year.  As with my best friends from college and medical school, I knew we would maintain contact and connection, just in a different way.  We can’t stay in the nest forever—now is the time to fly.

In thoughtfully constructed journaling exercises and discussion groups, we reflected, consolidated, and synthesized ten months of learning.  We also examined our personal and professional evolution over this time, growth and movement in fluidity and complexity.  We explored aspirations and imagined the future state of this work in our natural habitats.  Finally, we sat in a closing circle.   Having each shared our own reflections, the group offered each friend observations, affirmations, and well wishes in what I can only describe as the most loving communion.  Each person’s strengths were articulated and amplified.  We acknowledged one another’s challenges.  We celebrated each other’s engagement, perseverance, contributions and triumphs.  Finally, sustained mutual support was extended around the circle, wholeheartedly and without qualification.

In my opinion, we formed the kind of community that we all want to lead.  Tony and Diane led us all by example, deliberately, artfully, and mindfully.  They live the principles they teach; they lovingly and patiently showed us the way.  In the end we discovered our own capacity to each write our own next chapter(s).  By making us feel seen, heard, understood, accepted and loved these ten months, our teachers inspired us to do the same for others.  And that is the strongest foundation for building our houses of positive change agency.

Now we go forth.  We’ got this.

Onward from 2019: Learnings and Intentions

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Friends!  WHAT a year, no?  How are you feeling here at the end?

In this post:  3 key learnings, 3 high intentions, and my 6 recommended life readings.

What resonates with you?

What would you add?

For a thoughtful and inspiring look on the coming year, check out Donna Cameron’s post from yesterday.

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3 Key Learnings of 2019

Complexity

“When we try to pick out anything by itself, we find it hitched to everything else in the Universe.”  –John Muir

“All that you touch, you change.  All that you change, changes you.” –Octavia Butler

We all live in inextricable connection, like it or not, know it or not, want it or not.  Every interaction has potential for benefit and harm, and the scale is exponential.  Some may find this idea daunting, overwhelming, or untenable.  I find it reassuring.  The idea that some cosmic life thread connects us all, that we are made of the same stuff today as that which existed at the dawn of the universe—this gives me peace.  It encourages me that everything I do in good faith could make a difference.  You really never know how far a small gesture or sharing will reach for good.

The 3 Tenets of Relationship-Centered Leadership

Not so much learnings as a synthesis from LOH training, these are the current foundation statements of my personal and aspirational leadership tenets (iterations likely to evolve over time):

  1. Founded on curiosity, connection, and fidelity to a people-centered mission
  2. Attendant to the relational impacts of all decisions, local and global
  3. Respectful of norms and also agile and adaptive to the changing needs of the system

Having defined these ideals for myself, I am now fully accountable to them.  And I hold them as a standard for those who lead me.

Being >> Saying or Doing

Saying and doing compassionate, empathic, and kind things are necessary and noble.  And they are not enough.  These actions ring hollow without honest sincerity behind them.  People feel us before they hear our words.  Our authentic presence, positive or negative, originates from within.  It manifests in posture, facial expression (overt and subtle, intentional and subconscious), movement, and tone and cadence of voice.  Fake it ‘til you make it—saying and doing things because we know we ‘should’—only gets us so far.  We humans possess a keen sense of genuineness—it’s a survival instinct.  If we accept that a meaningful, productive life and effective leadership in particular, require strong, trusting relationships, then we must cultivate true compassion, empathy, and kindness.  That means suspending judgment, managing assumptions, and holding openness to having our perspective changed by all that we encounter (see first key learning above), among other things.  This may be life’s penultimate challenge—our role models include Mother Theresa and the Dalai Lama.

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3 High Intentions for 2020

  1. Continue to ask more and listen better for people’s personal and unique meaning making—not just patients but all people—attend to souls
  2. Let go perfection
    1. All relationships are not great, and it’s not all my fault
    2. Some people/relationships and circumstances challenge my best self and skills more than others
    3. It’s the honest, sincere, good faith effort, and the learning from imperfection and failed attempts that matter
    4. Some relationships are better ended
  3. Guard against judgment, arrogance, and cynicism

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6 Recommended Life Readings—the 6 most personally impactful books I have read in the last decade:

The Art of Possibility by Rosamund Stone Zander and Benjamin Zander.  Scarcity thinking, competition, and looking out for number one hold us all back.  Stepping fully into our central selves, claiming our full collective agency for creativity and collaboration, and manifesting all the good we are capable of—that is the discovery of this book for me.

Start With Why by Simon Sinek.  In my opinion, the most eloquent and resonant writing on the purpose-driven life.  The freedom and creativity that flows forth therefrom—it all just gives me goosebumps.  Sinek’s The Infinite Game may eventually make this list too, once I have integrated its content and learnings more fully.

Rising Strong by Brené Brown.  Strength and vulnerability, confidence and shame, individuality and belonging—these are the essential human paradoxes that Sister Brené reconciles with gritty aplomb through real life stories as well as grounded theory research.

Big Magic by Elizabeth Gilbert.  Be you, all you, all in.  Love thyself—flaws, failures, and falls all included.  Make things.  Because that is what we are put here to do, for ourselves and for one another.

Leadership and Self-Deception by The Arbinger Institute.  Perhaps no book explains the profound importance of being better in order to do better, better than this.  And it took me almost all year to really comprehend, and then begin to apprehend, the concept.

Being Mortal by Atul Gawande, MD.  I started and finished this one on vacation this past week.  Dr. Gawande is my favorite physician writer.  I consider this book required reading for all physicians for sure, but really for all people .  “The death rate from life is 100%,” a wise patient once told me.  In modern western society and culture, multiple intertwined and complex forces hamstring our ability to live and die well and at peace.  This book is a brilliant compilation of heartrending personal and professional stories, neatly folded with history, research, and practical information for improving this sad state of things.  It is also a guide to the hard conversations that we all should really have—now.  It has both validated what I already do in my practice, and profoundly changed how I will do things hereafter.  Thank you, Dr. Gawande.

*****

Best wishes for Peace, Joy, Love, and Connection to all.

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November 19:  Board Review Makes Me Better, For Sure

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NaBloPoMo 2019

Are you required to do continuing education for your work?

Since 2013, the Illinois Chapter of the American College of Physicians has run a weekly internal medicine board review webinar, MKSAP Live Online Study Hall.  We use questions that ACP publishes through the Medical Knowledge Self-Assessment Program, covering topics in general medicine and its subspecialties, including cardiology, pulmonary, infectious diseases, and rheumatology.  Every Tuesday night at 8pm Central time, two of us moderators and one webinar organizer get online and review about 14 questions, SAT-style.  We interact with audience members through a chat function on GoToWebinar, and we poll some of the questions each session.

I love this program for multiple reasons.

First, I was there when it started.  Gathered around then Governor Dr. Marie Brown’s dining room table, a handful of local ACP members brainstormed and created what is now an international, comprehensive internal medicine board review webinar series.  After some playful, off-topic, post-prandial banter between Dr. Sean Greenhalgh and me, our colleague across the table said wryly, “I’d watch that for an hour.”  Hence the dual-moderator, morning radio DJ style webinar was born.  That was in the fall of 2012, and the Study Hall is now halfway through its third two-year cycle.

Second, I get to hang out with my doctor friends online.  Besides Marie and a couple others, I did not know any of the dozen folks involved in the project before that night at her house.  We did improv workshops at the beginning to form our team and ease our communication skills.  Since then we have all become friends—a clique, even.  We have followed kids’ graduations, births of babies and grandbabies, and some personal challenges as well, all while getting together every few weeks to talk shop for an hour online.  We have even become celebrities of sorts—first at Illinois Chapter meetings and now sometimes at ACP National, people come up to us to say how much they like the program.  We’ve become a fixture in some colleagues’ lives.  We feel pretty proud and special about that.

The best thing about the Study Hall, though, is that just in the space of one hour on a Tuesday night, I am consistently humbled by the sheer volume of knowledge there is to absorb, just in internal medicine.  This is only one specialty of the whole medical profession!  And it’s not just the volume—it’s the complexity, the context, and the ever-evolving research, diagnostic and treatment development, and guidelines.  MKSAP publishes a new set of comprehensive questions every two years, and I do not envy the writers their colossal task of keeping us all up to date.  Without fail, every session I learn something that I will use the following week in clinic.

As this month of daily posts progresses, I feel increasing awe and gratitude for all of the people and opportunities in my life.  Thanks to all my colleagues, leaders, family and friends who make this life so full and loving.

November 18:  Relentless Curiosity Makes Me Better

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NaBloPoMo 2019

“Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are now written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.”
― Rainer Maria Rilke

Tonight, in the month of gratitude, I feel deeply thankful for Coach Christine.  I might have been a curious person all along, but it was not until I got a life coach that I learned the vast and profound value of curiosity in every realm.  As I wrote earlier this month, standing always in curiosity liberates my mind.  It relieves me of unnecessary urgency for an answer.  I can exercise professional creativity in forming better and better questions, and the answers (often multiple, intertwined, and intriguing) emerge more easily and artfully than if I chase them demandingly.

The business of medicine is to solve problems, to heal, to cure.  So we assume that the faster we get to answers, the better.  And they had better be the right ones, because lives are at stake here!  It’s always interesting to me when patients talk about my work as ‘saving lives.’  I can’t remember a time when I could actually make that claim, at least at all directly.  But to my colleagues—emergency medicine and critical care docs, trauma surgeons, suicide hotline counselors—thank you, you really do save lives every day!

I love primary care because I usually have the luxury of ‘(living) the question.’  When patients present with new problems, as soon as I know they are stable, I get really excited.  I’m liberated to get deeply curious, ask as many questions as they will tolerate, paint the big picture together.  I follow the standard physiologic and diagnostic process initially, which often yields a straight forward answer and plan of care.  But life and work would be pretty boring if that were always the case.  When the usual suspects are all acquitted and the mystery persists, that’s when things get fascinating.  This is when I really get to know a person.  When I ask truly open, honest questions—the questions I don’t know the answers to and that are not meant to lead anywhere—I never know where the conversation will go.  And I always learn something new and relevant, something that helps me connect.  This is the information that makes a person memorable, because it is truly unique to them.

One of my favorite moments in a patient encounter is when I have to pause a few seconds to form a really good question.  What do I really want to know, what am I after, what will really break open this conversation?  It happens regularly, and wow, what a rush.  OH, I just never know what I will learn!  You’d think people would get impatient and grumpy with such prolonged, sometimes meandering interrogation.  But I find that they often lean in, look me in the eye.  They get on the train with me and look as eagerly as I around the next bend.  What will we find?  Let’s explore together!

Relentless Curiosity.  It’s the funnest part of my work.  I love it.  And as we all know, loving our work makes us better.

November 17:  Elasticity Makes Me Better

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NaBloPoMo 2019

What was school like for you growing up?  Were you bored?  Confused?  Frustrated?  I had a pretty easy time, but many of my classmates did not, even the ‘smart’ ones.

In high school I was on the speech team.  One of my events was persuasive speaking.  I chose one year to advocate for teachers to broaden their teaching styles to match a wider variety of learning styles.  I used the Gregorc Mindstyle Delineator as an example of how styles can vary (mine is Abstract Random, go figure).  It was an interesting thesis and I sincerely believed what I wrote and presented in those 8 minutes each weekend.

Thirty years later, I wonder how much I walk this talk of meeting people where they need me.  Simply asking the question, raising my awareness, makes me better.

Parenting.  It doesn’t matter how many parenting books you read or how well you think your parents raised you.  General principles apply, of course.  But every kid is unique, and we parents do better when we realize that the methods we use for anything on kid #1 won’t necessarily work with kid #2, #3, an onward.  Flexibility is key to a happy and functional household, for getting out the door every morning without yelling.

Marriage:  According to the Dr. John Gottman, about two-thirds of marital problems are perpetual, meaning they will never actually resolve.  So how do couples stay together successfully?  Among other things, they learn to accept one another and work around the hard stuff.  At least partially, we have to soften our rigidities, learn to bend and sway, embrace the supple, intimate dance of commitment.

Teaching:  Not all students learn best by watching.  Not all learn best by doing.  Or by hearing, mimicking, or competing.  Luckily, medical education gives trainees multiple platforms on which to acquire the necessary knowledge and skills to care for patients.  For all its flaws, our profession actually does well here.  I’m happy that I realized this in my own experience.  When I precept students in clinic, they shadow, scribe, see patients alone or lead a joint encounter, so they can experience the work from different perspectives.  I think this mutual versatility and adaptability makes us all better.

Patient Care:  Over the years I have accumulated myriad articles and books to share with patients.  But not everybody’s a reader like me.  Not everybody wants to meditate or journal.  Some people do better with a personal trainer, others in spin class.  It’s my job to assess how each patient is most likely to succeed in health habit optimization, and present the most appropriate resources for consideration.  Primary care definitely does not work with a one size fits all approach.  So now I include audiobooks, podcasts, phone apps, and YouTube videos in my repertoire of medical information sharing.  I am blunt when it’s needed, and also gentle and diplomatic.  I can speak from the head and the heart, often both at the same time.

Speaking Engagements:  Here is where my elasticity has grown the most in recent years.  For the first decade of my career, I still used the expository presentation style I learned in high school.  Thankfully in 2014, I watched Nancy Duarte’s TED talk on transformative oral presentations, and then read her book, Resonate, in 2015.  Make the audience the hero, she says.  Tell a story, contrast what is with what could be, paint the vision of the blissful future clearly.  Engage people’s emotions and aspirations.

This is not easily done with Power Point decks full of words.  But words are my medium!  I had to add color, diagrams, cartoons, photographs.  I started making my presentations more interactive, between myself and the audience, and between audience members themselves.  Now I have people stand up and move their bodies.  I may bring raisins to my next talk and do a mindful eating exercise.  I need to learn how to embed music and videos into my slides.

What is the objective in all of these relationships?  It’s connection.  How do we best connect?  We reach out.  We extend ourselves to others—make ourselves relaxed, flexible, spring-like.  That is how we gather people closer.  It’s not formless or weak.  A strong elastic maintains its integrity even under high tension.  But it must be stretched often, or it becomes stiff, brittle, and ultimately ineffectual.

 

November 10:  Experimental Questions Make Me Better

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NaBloPoMo 2019

What’s the most interesting question your doctor asks?  What effect does it have on you?

I get to ask some really fun and interesting questions of my patients.  They often come about spontaneously, then I realize how helpful they are, and I integrate them into my routine interview.

It was almost ten years ago now that I was seeing a pleasant young woman for the third time.  She had recurrent, nonspecific physical symptoms, and felt down.  She was having a really hard time at work, and it was having a significant impact on her overall health and well-being.  Around the same time I saw another patient, a young man.  He felt well overall, but was also not happy in his job.  I remember casting around in my mind, looking for a quick and easy way to quantify the negative effect of these patients’ negative work experiences on their health.  I can’t remember which visit sparked the 0-10 stress and meaning scale questions, but it was one of them, and then I repeated the questions on the other soon after.  These were my first two, unsuspecting, experimental question subjects.  On a scale of 0 to 10, how high do you rate the overall stress of your work?  That was easy, but I also had to figure out whether there was some benefit that was worth the cost of the stress.  So: On the same scale, how high do you rate the overall meaning of your work to you?  The bottom line is that we can tolerate very high levels of stress if the work is meaningful—for sustainable work, the meaning-to-stress ratio needs to be 1 or greater, and overall meaning is best at 7 or higher.  That year I realized I could create deeper, more helpful, more insight-revealing questions in my patient encounters.

My own work meaning rating rose by at least a couple integers almost immediately.

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Since then I have consistently asked about body signs of stress, resilience practices, the proportions of threat vs. challenge stress at work or home.  Since I last wrote about these questions in 2016, I have continued the experiments.

By 2016 I was also using the elite athlete analogy with my patients, asking every year about habits in the 5 reciprocal domains of health (after talking about stress and meaning at work): Sleep, Exercise, Nutrition, Stress Management, and Relationships.  But after asking the same questions for a couple years in a row, both my patients and I get a little bored.  So in 2017 I went a little deeper in the relationships category.  After confirming marital status, ages and health of children, I started asking, “Tell me about your emotional support network,” because the more I am reminded of the critical importance of emotional support in our health, the less it makes sense to not ask about it directly.

With each additional set of questions, I learn more about my patients. I learn how people understand the questions—sometimes it’s totally different from my own understanding, and the conversation about the meaning and objective of my asking gives me wonderful insights into people.  Patients are remarkably open and honest in their answers, which always reminds me of the honor and privilege of my role as physician.  The answers to these questions are what allow me to imagine my patients in their natural habitats, engaging with their work and the people in their lives.  The answers provide context and texture to the other patterns we uncover in health habits, and we often come together to a better understanding of both the origins and consequences thereof.  I can’t speak for my patients, but I always come away feeling just a little more connected.  I get goosebumps just thinking about it.

This year I’m excited to introduce 4 new questions.  It started out as three.  The third one wasn’t landing quite right initially.  I wasn’t asking what I meant, and I couldn’t quite articulate what I was after.  So I experimented with the wording until I got to the current state:

  1. In the coming year, what do you see as the biggest threat to your health?
  2. What is the biggest asset?
  3. Having answered these, how does this affect your decision making going forward? …And other iterations I can’t remember anymore
  4. One year from now, when we meet again, what do you want to look back and see/say about your health, relationships, and whatever else is important to you?
  5. (then the corollary question that occurred organically once and I then incorporated–) In order to make this vision a reality, what support do you already have or need to recruit?

I have asked these questions since July.  I always think to myself how I would answer for my patients, based on what I know about their circumstances, habits, and biometrics.  About two thirds of the time, our answers are the same.  Patients seem to receive them well, too.  One asked me to email them to him, so now I offer to email them to everybody.

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You might imagine that I think these questions make me a better physician.  That may or may not be true.  All of these questions make me better—a better, more self-aware person—because I also ask them of myself.  What is my meaning:stress ratio today?  This week?  This year?  I assess the threat/challenge ratio of my own life stressors, especially the acute ones.  I have had the same body signs of stress for many years, but in 2019 I may have developed a couple new ones, darn.  What’s the biggest threat to my health?  My hedonist impulses, no question.  The biggest asset?  My Counsel—those best friends and confidants.  What is my vision for my health a year from now?  I only answered that for myself a week ago (and I’ll keep it to myself, thank you).  And what support do I have/need?  I’m still working on that one!  That I don’t already know the answer to this one surprises me—I assumed I knew, but when I sat down to think about it formally, I realize that this may be the missing piece that holds me back from achieving some of my personal health goals.  HUH, how fascinating!  Did I not just write about how I question some of my patients’ ‘Lone Ranger’ method of self-care?  Well hello kettle, I’m pot!

Now, off to ponder some more, yay!