Category Archives: physician

Love Letters

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Sunrise, Sylvan Dale Guest Ranch, Loveland, Colorado. Photo courtesy of Dr. Anne Dixon

When did you last write a love letter? Send it?

What constitutes a love letter in your mind?

Depending on your definition, maybe you’ve written/composed and sent them your whole life and not even known it? Sometimes I think this is the case for me… definitely lately. Without question, I have written and sent countless ‘conventional’ love letters in my 50 years. Since at least 4th grade, I have professed and proclaimed love for and to many, in words, on paper. The pretty paper and pen fetish started early, and has been put to very good use. Responses have varied; looking back now I can take it all so much more lightly than I did in my youth. Putting your heart out in the open, wow, that can be intense. Exhilarating, giddy, tremulous, brave, honest, fearful, uncertain, upright, vulnerable. I wonder how many reciprocations, in any form, it takes to make up for all of the non-responses and rejections? I suppose it depends on all the things–to/from whom, magnitude of emotion, stakes of the relationship (on my end), expectation, context, timing… So much of any experience is determined by my own mindset at the time, the stories I tell about myself and the other person. I smile (smirk? cringe?) as I write this today, even chuckle, because oh my gosh, I took and gave it all so seriously back then! *sigh* The peace and steadiness that comes with age… There is a comfortable looseness, a confidence that comes from loving over decades. Relationships come and go, dive deeply and float in turn; the fluidity of it all emerges over time, teaches me to flow with it more and more easily. Awareness and acceptance of this natural, organic rhythm liberates me to express more freely and with less attachment… and paradoxically, the rewards of reciprocation feel that much more bright and lucious!

I still have a stack of New Year cards to send. This involves colored pens, stickers, stamps, and trips to the mailbox. I love it all. I figure it’s okay if they’re late, because it’s a personal greeting, something I take time to do specifically for someone. People appreciate that. It’s a form of love letter, I have decided, and when does anyone not want that?

Lately friends have sought me for reflection and advice. Our conversations are heartfelt and connecting. What an incredible honor for me, to be trusted so. I take that very seriously, to be sure. But the feeling in these exchanges is not heavy. Rather, it’s deep, close, bonding, meaningful. I find myself writing summaries and reflections afterward, hundreds of words’ worth. I feel a need to document and share back, to verify the thoughts, impressions, values, and goals; I want us both to record the integrity, affirm our own relationship and shared humanity with others in our lives. It’s not a high or rush I get from these encounters. It feels slower, an unfolding, shared in confidence, soft tones and close proximity, even if over the phone. These summary ‘love letters’, as I have come to think of them, are meant to reinforce what I see as my friends’ strengths of character, their core values, and the resulting alignment of their goals and actions. I keep these missives for myself, as well, because the connection nourishes me at least as much as it may help my friends.
They are love letters.

As seen on Instagram

I still love this meme so much. What a simple and moving reminder about what’s nost important in life–our relationships. The best part is that when I send the text, drop the card, and leave the voice message (all love letters), just the act itself feeds me already, whether or not a response ever comes. Giving love begets yet more love–the threshold potential for this positive feedback loop is so low, it’s a wonder we don’t walk around eurphoric all the time, just from feeling love for others, HA!

For every executive physical, I debrief with my patient at the end of the day. We review biometric data and test results. This discussion includes an Action Plan, in which the dietician, exercise physiologist, and I make health behavior recommendations in the context of the person’s current life circumstances. Travel, phase of family life (eg little kids vs young adults, empty nests, and aging parents), work role/stress/status–anything relevant to their health is assessed and factored for specificity to person, place, and time (hint: everything is relevant). Over the years, and the past year especially, I reflect on patients’ goals, fears, and values in all domains of life, in addition to body mass and fasting glucose. I talk about relationships, a lot. New patients seem surprised–most often pleasantly, sometimes not… I can attune and dial back if needed. Without fail, however, the more someone discloses, the more we share (because there is always two-way sharing), the more meaningful and dense my action plans get, the more I get to love on these patients, I have only recently realized. It’s okay if they don’t accept it–not everybody wants to feel loved by their doctor. For those who do, however, I am all in…and the rewards are exponential, at least for me.

I see you.
This is what you mean to me.
This is what I wish for you.

Every time we express these, when we convey them to someone we care about, then I say we have sent a love letter. I personally value the handwritten kind most–the swoop and pressure of writing implement, the acutely vulnerable yet high potential permanence of paper, someone’s thoughts and feelings in a particular time and place, documented so concretely, tactilely–to hold, see, and smell it all at once–the uplift almost defies description.

If you seek inspiration for your own love writing, I recommend two men whose work I admire:

Grant Gosch writes sensual missives and posts with accompanying black and white photographs that stir body and soul. Follow him @saltfox_writer on Instagram. You can receive his Saturday morning love letter via email; subscribe at http://www.grantgosch.com. I am 80% through his first novel, Kingfisher Lane, and may very well bold it on my 2024 list. Additionally, Grant offers commissioned love letters in exchange for monetary support of his writing–believe me, this is high value. I have no financial interests in Grant’s work. I simply admire that he puts his heart out in the world, to connect and write on behalf of any of ours. He is a gifted writer, possessed of highly attuned and effective emotional-verbal integration, offered to us from the wilds of the Pacific Northwest.

JP Greene also writes on love and life with eloquence, heat, and edge. Follow him on Insta: @typewrittenlovenotes. JP also offers a weekly newsletter, sent from Fort Collins, Colorado, written thoughtfully and with purpose. His second book, The Beauty of Sadness, drops on April 4. I have no interests in JP’s work, either, other than to amplify it because I think the world is better for his expression.

Funny that both of these writers choose to present their work on paper, typed old school on machines that deliver ink via ribbon. I imagine that is why their work, among other reasons, resonates so deeply with something in me. Kindred.

Love letters. When and what will you send next?

Also from Instagram, can’t recall source, sorry!

Medicine: The Science and the People

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The Quad, UChicago

Friends, have I told you all lately how much I love my work?

Nerding out over the science is just so fun, even more so because I don’t have to be the one doing the research. I just get to benefit from it! That we can know the chemical mechanism of how hemoglobin’s oxygen affinity changes with altitude, how sodium and calcium channels work in kidney and muscle cells, and how caffeine and adenosine affect the brain–how amazing is that? And that neuroscientists like Adrian Owen have figured out how to communicate with locked in folks by putting them in a functional MRI machine, asking them yes or no questions, and having them answer by imagining either playing tennis or walking through their house–I mean how crazy awesome is that?? And did you know the father of modern scientific surgery started out as a body snatching anatomist? 

OH the science, I just get giddy about it–pretty much daily!

And in the end, it’s still about helping people–helping the person in front of me right now. The best way to do that is to apply all of that vast knowledge and expertise to the human I’m with today, in their current circumstances, phase of life, and psychophysiologic state. I get to take all of the science I can possibly comprehend and use it to help you, the unique individual. *sigh* *gawk*

I cannot do any of this without knowing you. How do I know you? I query and observe. I attune and attend. I stay quiet, I listen, watch, feel. I try not to interrupt. I ask open, honest questions, and I wait for you, your whole self, to emerge. I look and listen to understand your experience from your own point of view. I do my best to self-regulate, and not project my own judgments and prejudices onto you. It’s so much all at once–I have to be slow and quick at the same time, hearing, seeing, retaining both your output and my own processing, holding it all to let out with appropriate filters and timing–and I love it all!

You know your body and mind (to the extent that you can). I know the body, some of the mind, and a lot of science (as well as I can). You know some of your own patterns, I know some patterns from thousands of patients seen over twenty years. We can, together, apply our collective and collaborative knowledge and awareness to your current context, in service of moving you toward your goals. Only you can decide what actions are worthy of your time, energy, and resources; only you can reassess and alter those equations.

My wish for you is to have the fewest possible regrets at the end of your life, whenever and however it happens. How can I help? How can the science help? How can it not? How can science actually make it worse? 

Medicine is the practice and discipline of lifelong learning of the science, yes. And its core is about caring for people. We make the journey together, my patients and I. What do we share? Here’s my list:
Information
Interpretation
Responsibility
Respect
Privacy
Relationship
Power
Agency
Decision making

We are humans in relationship–with ourselves, with one another, with our environments. It’s all so much, so dense and complex. And yet in the room with you, talking with you, examining you, I can usually distill to one or two central concerns and objectives, for now and the future. It’s gratifying for us both, and it keeps us connected, strengthening our relationship over time and shared experience.

I can hardly think of a better way to spend my professional life.

Trust and Influence–Because Shane Said So

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Instagram, @shaneeastreads, 1-3-2024

What is your morning routine? Do you run it, or does it run you?

In the video post of the screen shot above, my romance narrator hero Shane East reports on some morning advice he heard on a podcast on New Year’s Day (Huberman?), and invites followers to try it with him:
1. Upon waking, get sunlight for at least several minutes before getting on any screen
2. Delay caffeine intake for at least 45 minutes after waking
For the second, he describes the relationship between caffeine and adenosine, the neurotransmitter that promotes sleep drive. Simply, caffeine is an adenosine antagonist: when it sits on adenosine receptors in the brain, which normally slow cellular function and promote sleep, it has the opposite effect, promoting wakefulness instead. 

I dived into the rabbit hole that yielded the articles linked above, trying to understand the rationale behind that second recommendation.
My takeaways:
1. Transition from sleep to full wakefulness takes time; better to let the body do it naturally by drinking water (we get dehydrated overnight) and getting light (preferably full spectrum sunlight, but get what you can that’s not a screen) on the retinas before doing anything else.
2. Caffeine can prolong and/or amplify effects of morning norepiniphrine and cortisol, which have stimulatory effects on heart rate, blood pressure, and other systems of the body. It can interfere with physiologic adenosine recycling in the brain and, depending on dose and interval, disrupt our intrinsic sleep-wake patterns. Introducing caffeine later after waking, when adenosine levels are lower and more stable, can mitigate this disruption.
3. None of this matters nearly as much as simply getting enough sleep (both quantity and quality) as many nights a week as possible, to obviate the need for stimulants in general.
But caffeine and adenosine are not my point in this post.

Rather, why am I suddenly so motivated, almost giddy, to act on this advice just because Shane said so? Really? Not when I heard it in Why We Sleep, not when I have ever read it elsewhere. Not because I’m a doctor and I know it’s good for me and I want to walk the talk. No. My book hero got up on the third day of this new year, made a 00:01:03 extemporaneous video sharing something cool he had recently learned, invited us fans to try it with him, and that lit one of the biggest behavior change fires under my butt since I joined Ethos nine months ago.

Readers of this blog may know my night owl tendencies. I have been known to post at 1:00am, then get up at 7:00 for work. That hasn’t happened in a while, because I’m working on it! And yet, habit change is hard. I have wanted for years to get up early to write Morning Pages, a creativity and wellness practice that calls to me. But before last week, I slept through all the calls. On a good day, if I left on time for work, I’d write in the car after turning off the engine, before walking from the parking garage to the office. For seven consecutive days now, I have risen with my alarm rather than snooze it. I sit up, turn on my full spectrum bedside lamp (the bulb came with my dawn simulator years ago, and has survived its associated device), grab my journal and write three pages, stream of consciousness, so I have something to distract me from my phone and keep my eyes open to light while I wait for my caffeine. I only look at my phone to turn off the alarm and get my writing playlist going. Win-win-win-WIN!
By the end of three pages, here are my consistent findings so far:
1. I feel alert.
2. My mood is excellent.
3. I’ve gotten out ideas that marinated overnight, or maybe worked out some question I had gone to bed with the night before. Or maybe I uncovered addtional questions yet to ponder. Regardless, I have just spent 15 minutes doing something I love, first thing in the morning!
That’s all pretty amazing.

I have known about the benefits of drinking water in the morning for years. I keep a water bottle at the bedside. But it wasn’t until last week that I started chugging in the morning, while I write. And because I’m getting up earlier and spending more time awake and out of the kitchen, my morning coffee consumption now automatically occurs at least 45 minutes after waking. It all feels almost easy.

And bonus: This new practice seems to have created space for insights and ideas to emerge throughout the day. I’ve made entries in the book journal almost every day this week, and momentum grows toward writing actual chapters and a proposal. I have also realized this week that since ideas so frequently occur as I drive to work (I often grab notebook and pen, scribbling while stopped at lights–hence the parked car journaling), I will now forgo the input of audiobooks (ugly cry face) on the morning commute to facilitate my own original output in that naturally creative time. And I attribute all of this to Shane.

What is with this phenomenon?

Normally I would cogitate long and hard, analyzing the psychology of motivation, cross referencing counseling practices for behavior change, looking back at my own past patterns, etc. Not this time. Today, I’m satisfied to wonder at it all a little while, marvel at the minor miracle of it, and then chalk it up to the utterly irrational nature of human behavior. I love and admire Shane as a person. I see him as trustworthy. I appreciate that he shared this advice, prompting me to search and learn more, nudging me toward my better self. I want to report to him that I accepted his invitation and it helped me.

Because that’s one of the best relational rewards, right, when someone tells us how we help them, how we make their lives better? Isn’t this why I’m a physician? My fondest, most loving memories throughout my career are patients and trainees telling me how I have helped them–yes, it’s my job and still, any amount of validation, no matter how small, matters. It’s even more meaningful after we have gone through multiple trials in their lives or training together. The more we acknowledge this bond, the stronger it gets, the more we trust, mutually.

Patients and students absolutely influence me. Because they trust me and consider my advice, I want to be worthy of it. Trust is built slowly, earned with time, energy, and effort. How better to honor that trust than to practice what I preach, visibly, right alongside my charges? Maybe this is why Shane’s video resonates? He’s getting in the boat with us fans, acknowledging the challenge, inviting us all to journey together, do our best, and see what happens. Had he said, “Hey, I learned this cool new thing, you should try it! Good luck, tell me how it goes!” I would have a very different response.

Trust and influence. They are irrational, driven by our qualitative, ineffable, limbic and sometimes labile sense of connection. I think of trust like an oak tree–grown over many years, strong and sturdy, and also susceptible to irrevocable damage in a single breath–a broken branch never grows back. There is no substitute for the attention and nourishment, cultivated through relationship, required to maintain strong trust and real influence.

Though my energy for this new habit is high today, change is still hard. I have significantly altered my daily routine, counter to what I consider to be my innate tendencies, which is not what I usually recommend. We will see how/whether I can sustain it. Maybe it will help that I was already approaching the threshold, and Shane’s video feels like just the little nudge I needed to push me over to the next best version of myself? Fingers crossed! Lasting change is most often incremental and iterative, requiring multiple trials. So I won’t be too hard on myself if by this time next week I am back to snoozing until the last possible minute to rise, rushing out the door 30 minutes later having written nothing and gulped a good portion of my coffee already. I can forgive myself the lapse and commit to trying again–maybe on days I don’t see patients? Something is usually better than nothing. We’re all here doing our best.

Anyway, Shane, if you read this, thank you. You have made my life better for a while, and now again, and given me more things to write about, for the past week, at least. I have two more blog drafts inspired by reflections on your video. I think of them as I walk to work, and I get Resting Peace Face from the gratitude I feel for the possibilities that have opened in my life because of you being you.

And now it’s late (but not too late). Temperature is -6F outside and I need to get up even earlier tomorrow to write, hydrate, and make sure the car starts. So it’s off to bed for me. I look forward to my Pages tomorrow morning–who knows what may come of this new habit? I’m sure I’ll let you all know as it emerges.