Category Archives: physician

The Expert and the Student

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What do you take for granted that you know and do?
How do your conversations with colleagues differ from those with ‘laypeople’?
How does your specific expertise emerge and manifest outside of its own domain?

Friend recently told me about the time his friend offered their Adderall (a stimulant used to treat attention deficit and hyperactivity disorder) for his full body, multi-system allergic reaction to food (which technically constitutes anaphylaxis and should be treated with epinephrine, or at least a strong antihistamine like cetirazine [Zyrtec] or diphenhydramine [Benadryl]). I had immediate, strong, and mixed feelings and thoughts: What? Oh, your friend was trying to be helpful.. and that is absolutely not the right thing.. and omg, what badness could have happened? ANTIHISTAMINES FOR ALLERGIES! And this is why everybody needs an accessible primary care doctor, FFS. Okay, okay, self-regulate. Friend has lived with his allergies for however long, he has apparently handled it fine thus far; this is not my business. Unsolicited medical advice is not often welcome, Chenger, so zip it! And GAAAAAAH, my dear friend, the next time you have an exposure, I pray please for you to have more knowledgeable folks around you! OH that self-restraint really challenges me sometimes.
I share this story as an example of how my doctor mind is always present, always assessing. I felt caring, protective, and concerned when Friend told me, and not at all dismissive or condescending, so I hope that is not how it comes across. All I want is for Friend to be well, to have all he needs for that, and to help if I can, within appropriate boundaries. I hope I respected his boundaries well that day, while still conveying how much I care.

Opioids, anti-inflammatories, corticosteroids, Tylenol–they all address pain, and by different mechanisms, with different side effects, and can be combined and not in certain ways–I know these things. Blood count, chemistries, lipid profiles, iron, B12, CRP, sed rate, TSH–I have ordered and interpreted these and other ‘routine’ blood tests for almost thirty years now. I see patterns for fluctuations, correlates to behaviors, and advise accordingly. Pain, headache, dizziness, nausea, rash, shortness of breath, diarrhea, and myriad other things–I know what’s common and how to treat. I know what to do when I don’t know what’s happening. I know who to call for help. I know how to sit with you, my patient, when things are uncertain and you feel acute distress. I know how to listen beyond the objective answers to my questions. I see you, or at least I do my best. And the longer we know each other, the better I know how to help you, no matter what’s going on. I am an expert at primary care internal medicine.

“Routine,” Orthopod said to me before my knee surgery. I imagine he saw me as a fellow physician and assumed I understood the technical aspects of procedure risk and outcome expectations–which I did. And I was the patient in that scenario, anxious despite my expert medical knowledge, and possibly in part due to it, because I also know how things can go unexpectedly sideways in any operating room. “Routine for you,” I replied. I trusted him, the surgical expert, with my knee and my health. No longer a medical student, and still a learner in a different role, I felt vulnerable and safe. I think we both had a little a-ha moment then.

“Jacob, watch, please? Where does the movement start, again? What is the difference doing it this way versus that way?” In the gym, I am absolutely still a student, though I have been an athlete since adolescence. I have passed the prerequisites of anatomy and physiology. I understand force, mass, and acceleration. And every session, there is still no shortage of new knowledge, experience, and practice to acquire. This is what brings me back so enthusiastically–the more I learn, the more confident I get, and the better I can perform. I make steady progress because my teachers are both knowledgeable and approachable, generous and creative with their instruction.
I wonder what/where/how I might be more willing to study if I had such teachers?
How lucky that throughout my life, I have benefited from so many amazing guides, mentors, and coaches.

In preparation for this post, I listed things at which I am expert, proficient, and novice. Obviously the novice list is longest–humbling and inviting! The proficiency list is gratifying, actually, as I can stand justifiably confident in a variety of diverse skill domains–yay! And when I’m honest, the expert list is remarkably short, which is as it should be.

So it makes me think: How wonderful to be a student of everything, including in my own areas of expertise! Medical knowledge has doubled at least twice since I started training 29 years ago, and that rate continues to accelerate. There is simply too much for any generalist to know, even though we still know a lot and continue to learn about everything. Every time I connect with a specialist colleague, I walk away or hang up smarter and a better doctor for my patients. Bless my colleagues, all!

When I describe my interest in leadership to people, I say that I ‘study’ it. To some, I may seem like an expert. And though I do consider myself advanced in my leadership education, I will always consider myself a student, because every leadership role is unique and fluid. I will never be in a position to not learn and improve. I value humility; when I see it in experts and leaders, I trust them more immediately and implicitly. That is the kind of leader I aspire to be. Learner-leaders cultivate other learner-leaders by example. What an excellent, virtuous cycle!

Student mindset is growth mindset, a beginner’s mind. Maintaining it helps me connect more easily with others with whom I may mutually teach and learn from in loving and organic, natural and synergistic reciprocity. It keeps me open and improves, hones my overlapping, intersecting skillsets. It deepens all of my life experiences, inviting contribution from anyone I meet, anything I do. Everything blooms in brighter, more vivid color and texture; every day holds infinite possibility!

I meet experts in multiple domains every day, and I wish I had time to pick all their brains. My morning pages and brain dumps help me process and integrate all of these encounters and more. So much to gain, so many people to meet and love, so much connection in the offing, oh my goodness, it’s just too good!

My wishes for you, dear readers:
May you meet experts who enrich your life by kindly sharing their wealth of knowledge.
May you stand ready to receive their offerings with openness and curiosity.
May you share your treasures of life experience with generosity and humility.
May all of these encounters nourish you, mind, soul, and being.
And may it all make us better for ourselves and one another.

Onward!

What Do You Protect?

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What does this question mean to you?
What comes to mind first?

Voice actors I admire post about vocal rest and nasal/sinus care regimens, hydration, and air purifiers. Of course this makes sense; they protect the source and tools of their livelihoods.

It comes up with my executive patients often. Of all of their habits in the 5 reciprocal domains of health (Sleep, Exercise, Nutrition, Stress management, and Relationships), which are the keystone practices that hold them up and make it possible for them to handle the myriad pressures and responsibilities they shoulder? Exercise often emerges as a primary method of protecting their mental health as much as physical, so they may continue to withstand the demands of a work culture that actively threatens their health and well-being.

After some particularly insightful exchanges with patients and friends this week, I asked myself the question. What do I need to protect? With the next heartbeat, the answer was my empathy. Fascinating! This also makes sense–as a primary care doctor, I function best when I am fully present and attuned to the person in front of me, listening to their stories and concerns, doing my best to understand their subjective perceptions and experiences. Without empathy, I am both less effective and less fulfilled, both in my work and outside of it.

So what are my keystone habits, and how does protecting and strengthening them affect my ability to attune and empathize?

Sleep: This one is easy; I am a very good sleeper. It’s even easier now that I have decreased my weekly caffeine use by about 85%, thanks to 116 days of a new morning routine. I’m even getting close to seven hours of sleep a night now, much better than before (no more 1:00am blog posts!). I don’t think this directly elevates my empathy, but it definitely improves my mood and mental resilience.
Exercise: I have now maintained a regular and challenging exercise program for 10 years, well documented among the 600+ posts here. Strength, core, and cardio training make me more knowledgeable advising patients on their programs, and earns me credibility. I can empathize with the multiple adverse consequences of injury and the emerging limitations of aging bodies, and advise as both physician and fellow athlete.
Nutrition: This is definitely my achilles heel, my most vulnerable health domain. But maybe this makes me uber-empathetic to my patient’s struggles? Because is there anything our society shames and judges more than how we eat, while simultaneously surrounding us with the least healthy food options in gargantuan portions? We struggle together, my patients and I.
Stress management: Today I can confidently say that I lead by example in this domain, thanks to so many teachers, role models, and books. I can engage in almost any conversation with calm confidence, even when conflict is high. I can tolerate adversity and the attendant difficult emotions with far less agitation than even a few years ago. I recover quickly now. Even when a patient screams profanities at me, I can maintain both my composure and my empathy for their distraught state of mind. And then I can respectfully and diplomatically discharge them from my practice.

Relationships: I have said for a while now that the four domains above serve this one. Self-care habits indicate our relationship with self. How we care for and nurture ourselves influences how we show up to the people in our lives, both personally and professionally, and in public. Our behaviors in all of these realms also indirectly impact relationships between other people in our sphere of influence, know it, like it, want it or not. Without question, it is my relationship practices, internally and externally, that most uphold my empathy.

Quality time and contact in deep connection with my people are absolutely what hold me up, so that I might hold up others. It’s the best self-sustaining cycle, really. I have felt so joyful, so euphoric, so absolutely uplifted for so long but the past year in particular, because I attend to my relationships with intention and dedication. I schedule time to write, call, meet, share, and commune. Every encounter is meaningful and nourishes me, body, mind, spirit, and soul. Even meeting someone for the first time, I can bypass meaningless small talk and easily engage in conversation that connects. Who knows what I might discover about anything just by talking to someone, anyone? With this confidence, every stranger has the potential to be my next good friend, and it makes me practically giddy. As I moved from narrator to narrator at Readers Take Denver, I’m still floored at how effortlessly each conversation, even if brief, dropped into heartfelt resonance and mutual uplift. I will forever remember that day and that event as a shining example of the immense possibility of human connection.

My relationships feed my empathy, compassion, presence, openness, curiosity, and learning, and these practices then strengthen all of my relationships, new and old alike. It is the most rewarding positive feedback loop. I take pride in my emotional presence and observational and psychological synthesis capacities in clinical encounters. My friends also admire these skills that I exhibit, and I hope I model them for the kids. The world needs our best relationship skills now more than ever.

So the important question is not only what do you protect, but why?

What are our functional layers of protection, and what do they serve? In the end, how does it all align with our core values and life purpose? What good does it all do? What contribution does it help us make?

What we protect and why indicate what matters most to us, no?

Of course this could all be one giant rationalization on my part. It’s a very new question to me, and I will ponder it further. Thank you for pondering with me.

What else does it bring up, and where will the next questions take you?

Susceptible

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How do you assess risk?

For a long while now I have thought of risk in terms of intrinsic and extrinsic factors. For any given challenge, any individual (or collective) may have certain baseline predispositions for a certain consequence or outcome. The intersection of those innate properties with the external environment and conditions then create the actual outcome(s). This post is about self-awareness and self-regulation in service of mitigating risk in two situations: Infection and severe mental stress.

Infection

When was your last COVID vaccine? There have now been two booster vaccines available after the initial doses back in 2021. In the current endemic state of the virus, repeated vaccination feels less urgent than before. Some will continue to say ‘always’ or ‘never,’ but most of my patients want to discern more thoughtfully. I advise situationally. The following applies not just to COVID, but for any infection we may contract in the wild:

Intrinsic risk: What is your overall state of health? How many risk factors for infection and complication do you have (eg advanced age, respiratory illness, diabetes, other immune compromise)? What are your nutrition, exercise, and sleep habits, generally and now, and do they protect you or make you vulnerable (sleep deprivation and high mental stress increase risk)?

Extrinsic risk: What is your likelihood of exposure, in terms of intensity, duration, and novelty? What is your access to healthcare in case of severe illness? How would infection impact your function, livelihood, and the health and function of those around you (and what are their intrinsic risks, if you were to expose them)?

I did not get my second COVID booster until right before I traveled to Taiwan last month, even though it’s been available since last fall. It was mostly due to inconvenience, though I also did not want to spend a whole day in bed (my reaction to this vaccine), and I assessed my risk of infection and complication to be low. Then Husband got infected at the same time that Friend told me all about her severe and prolonged experience with long COVID, and I learned that cases in Taiwan were still fruequent and severe. I would be traveling alone with Daughter, who has asthma, spending 20+ hours each way and all days in country in crowded airports and public spaces. So while I had no overt intrinsic health risks, I was moved to vaccinate by both subjective and objective extrinsic factors.
I prioritized sleep the week before and all through traveling. I minimized caffeine intake. We wore KN95 masks in all public spaces throughout the trip and washed hands vigilantly. COVID infection during international travel is no joke, and we took no chances. Thankfully, we arrived back home uninfected and healthy.

When thinking about any infectious disease, I consider goals and trade offs. How important is it to avoid this illness, in general and right now? What are we willing to do and not do to prevent infection? What are the real costs of prevention and potential costs of illness? How can I minimize my susceptibility in a realistic, pragmatic, and balanced way? As a physician, I must consider infection impact not just on an individual’s health, but on public health as well.

Severe Mental Stress

In recent years, I have added a slide on distress tolerance to my wellness presentations. Practices like cold water to the face, paced breathing, and progressive muscle relaxation can help de-escalate us in the throes of acute emotional hijack, helping us get back from fight or flight to thinking clearly and acting reasonably. We have all encountered situations when we feel overwhelmed, out of control, and powerless. We each have our own unique triggers and reaction patterns, whether it’s performance anxiety, phobia, vicarious trauma, or simply rage, sadness, shame, etc.

Intrinsic risks for severe acute mental stress include history of trauma, tendency to avoid uncomfortable feelings, difficulty managing and expressing feelings or thoughts, and baseline anxiety, depression, etc.

Extrinsic risks for emotional hijack include inciting events that trigger past trauma reactions, often subconsciously. This could be anything from seeing someone else experience the harm you endured, to simply entering an environment similar to one in which you felt unsafe before. Certain words or gestures can trigger us–it can literally be anything. We each have a different threshold in any given situation, depending on the intersection of our current state, baseline traits, and real time conditions.

Susceptibility to mental stress, however, goes beyond simply passive innate attributes coming in contact with inciting circumstances. We all have our stress tendencies, many of which we can only partially control, if at all. Here is where our daily patterns, habits, and practices can really save us. Sleep deprivation and dehydration make everything feel exponentially worse, in my observation. Regular physical activity regulates the autonomic nervous system and improves sleep quality. Moderation of caffeine and alcohol help mitigate these substances’ disruptive effects on brain and body. Consistent self-assessment of mood and energy, what affects them, and anticipating challenges and threats on the horizon can increase confidence in our ability to meet them. Practices such as mindfulness, prayer, and communion with loving others also boost resilience–both mental and physical. And we cannot overestimate the profound importance of healthy, strong, and loving relationships to hold us up through anything life may bring.

For mental stress, while intrinsic psychological risks matter, our strong and consistent habits in the 5 reciprocal domains of health can (sleep, exercise, nutrition, stress management, and relationships) combine in synergy to minimize (or at least mitigate) our susceptibility to acute emotional hijack. Mindset, self-talk, communication skills, and attunement to others in daily life can set us up generally to encounter adversity feeling grounded and solid or vulnerable and insecure.

Thus, in addition to intrinsic and extrinsic risks, intrinsic assets also matter. The more we strengthen them when things are easy, the more easily we can call them forth when things get really hard.

I remind myself that though dividing risk into intrinsic and extrinsic is clear and helpful, it is also an oversimplification. History of trauma is not innate to me as a person, but the experience is integrated into my nervous system. Repeated subjective experiences accumulate and integrate further. I have, one could argue, adapted to it all in a way that protects me from recurrent harm in the future by alarming my system, mind and body, to similar threats, perceived and real. And while I practice my centering, grounding, inner peace methods, it also behooves me to honor and embrace my natural, un-peaceful tendencies. My best outcomes occur when I hold these all in dynamic balance, with nonjudgmental awareness and self-regulation. Anticipation, preparedness, and seeking support from trusted others also help mitigate my susceptibility to adverse outcomes and suffering.

In the end, I wish for all of us to live more peaceful, self-aware, self-efficacious lives. I want us all to move through good fortune with joy, and through adversity with fortitude and confidence, even while we allow ourselves to fully feel fear and distress. As an advanced practice in this domain, the better we understand our own intrinsic vulnerabilities and the conditions which expose them, and manage them effectively, the more likely we may recognize the unique struggles of others. We may all suffer less when these skills help us see, hear, and understand one another more empathically, compassionately, intimately, and lovingly.
We can, if we choose, help minimize one another’s susceptibility to pain and suffering.