Category Archives: relationship

The Sh*tpile

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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.  No big deal.

Once in a while, something moves us to start digging, like that sudden urge to clean out the closet.  We quickly learn that sh*tpile insides stay fresh and painful, like unhealed wounds when scabs suddenly get torn off.  Our eyes water, our senses are overwhelmed, and we want to escape, and fast.  Maybe we avoid that room for a while, or we come back driving a tank to flatten the pile, to the destruction of other property.  Maybe we get so disoriented, overtaken by the sheer mass and stench of sh*t, that in fits of rage and confusion, we start flinging. Unknowingly we pelt innocent passersby, or even friends and family, just because they live closest and walked into the line of fire.  Exhausted, we step out, try to clean up some of the mess, shower, and long for the pre-poop-flinging state of things.

To live a truly conscious life, though, we know we need to revisit the sh*tpile regularly.  It’s not good or bad, it just is–everybody has one.  Maybe each time we come better prepared.  We call up our gardener friends, and invite them to the hardware store with us.  They help us choose the right picks, shovels, and wheelbarrows for hauling sh*t out.  They stick with us through the dirty, ugly process, because they know us for more than our smelly piles.  We may pick up some books or otherwise learn about cultivating with manure–what tools we need, what to expect in the process. We start to envision a flourishing garden.  Maybe we enlist professionals–landscapers–to help us bring the vision to life.  Slowly, we may even find a whole community of gardeners, tending their own sh*tpiles, one crumbly corner at a time.

Parts of the pile will always remain.  It’s not good or bad, it just is.  We pass them onto our children, much of them long before we die–multiple sh*tpiles in the same house, imagine that, whew!  And hopefully the kids also benefit from the beautiful gardens that grow from our best selves–play in them, feel safe in them, and see that excrement is just a natural product of living a full life.

One day we may become exactly the gardeners who helped us first. Then we can compassionately help others shovel their own sh*t for the better. Or we can just start now.

Practicing My ABCs

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I lifted the boulder that was my head, looking once again at my clinic schedule.  Suddenly the day ahead loomed heavy, dark, oppressive.  No, not really, but I did feel abruptly bummed, when I had arrived that morning in a cheery mood.   My medical assistant noticed the change in my affect and inquired; I pointed to a name on my screen.  The same curtain of dread fell over her being.  “Oh no, I know him.  He’s a jerk!”  We had both made this diagnosis with conviction months before.

This day, I entered the exam room prepared to meet The Jerk.  I took a deep breath and noted my negativity.  I made myself ask extra questions to make sure I wouldn’t miss something, despite the urge to exit the room as soon as possible.  I reviewed medications, discussed his next colonoscopy, all in a perfectly professional manner.  The visit went without incident, nothing to write home about.  Was my care of him medically standard and objectively sound?  Absolutely.  Was I my best self?  Absolutely not.  The difference?  My best self is healing, and he got none of it.  I left Best Me at the door, along with my ability to connect to him as a person.  The other difference?  I suffered through that visit.  Physicians’ work fulfillment comes in large part through meaningful relationships with patients, and I got none of it—it was a lose-lose.

My son’s fourth grade teachers developed a resilience curriculum a few years ago.  The ABCs lesson resonated with me in particular.  (See the links below for more information on the concept.)

A stands for Adversity: The bad thing that happens to us.  In this case it was my patient’s previous behavior, which made my staff and me feel used and ignored.

B stands for Belief: The one(s) we make up based on adverse events.  For example, he is a jerk, a whole jerk, and nothing but a jerk.

C stands for Consequence.  Here’s the rub: The belief, not the adverse event, determines the consequence.  My diagnosis of Jerk hijacked my entire experience of him, precluding the human connection that could have benefited us both.

This story almost repeated itself months later, after a particularly contentious interaction with another patient.  I ranted colorfully to my colleague, who wisely reminded me that the patient might not be a jerk, that I could withhold that judgment yet.  When the patient came next, I took another deep breath.  Maybe she wasn’t a jerk, I repeated internally.  Prepared to meet her best self, I brought mine.  I could literally feel the difference—the tension in my neck loosened; my smile arose more naturally.  Our conversation hit some speed bumps, but we connected, somewhat—there was still something off about her behavior.  As I discussed her case with other specialists who met her, we all agreed that she probably lived somewhere on the autism spectrum.  Now in her late 50s, she had achieved remarkable success in her career, likely with little to no acknowledgement of, or accommodation for, her social challenges.  We genuinely admired her, when at the outset we could have dismissed her as just another Jerk.  In the end the whole team felt satisfied that we had brought our best to meet her needs, and we all learned along the way—a win-win.  By changing my beliefs after a typical adverse event, I steered the consequence of my own experience to a positive, productive place.

Life will never cease to hand us opportunities to practice our ABCs, and as with any skill, we will improve with each occasion.

Below are links to pages that describe the ABCs concept and it’s origins. I have no financial or other interests in these entities. 

http://www.dartmouth.edu/~eap/abcstress2.pdf

http://www.edutopia.org/blog/teaching-the-abcs-of-resilience-renee-jain

What Are You Looking For?

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One bright, spring Saturday morning in clinic, I met a pleasant middle-aged woman with a cold.  She was new to me, but I recognized her right away—educated professional, mother of two, loving wife, keeper of all schedules and task lists—the command center of her complex world.  Her symptoms had followed the typical arc of a viral upper respiratory infection—fatigue, sore throat, nasal congestion, headache, fever, cough—and it was the green snot that brought her in on day 5.  My physical exam revealed no signs of strep throat or pneumonia…

The relaxed calm I had felt heretofore began to unravel as I contemplated telling this woman, suffering at the peak of acute illness, that I would not prescribe an antibiotic.  In an instant I heard familiar scripts in my head:  She did not have time to be sick; she needed something to kill this infection right away.  She was about to travel and did not want to feel this badly on the plane.  Her regular doctor always gave her an antibiotic for this before.  The snot is green, that means it’s bacterial (it doesn’t)!  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?

Maybe it was the sunny weather that day, or the initial connection I had felt when we talked.  Amid the flurry of mounting anxiety, I had a flash of clarity:  What if I just asked her what she needed?

“What are you looking for from me today?” I queried.

“I just want to make sure I don’t need antibiotics.”

Imagine the absolute and complete relief of realizing that my swelling dread was, in fact, unfounded and unnecessary.  She needed reassurance, and probably formal permission to leave the air traffic control tower and go take a nap.  I cheerily listed all of my self-care recommendations, including a firm admonishment that she take care of herself ahead of all others for at least the next 24 hours, doctor’s orders!  The visit ended happily for us both.

“What are you looking for?”  Such a simple question, and key to understanding one another, as well as ourselves.  I was looking for connection, authority, relationship, and affirmation.  I wanted her to like me, and to trust that I knew my stuff.  And more than once before, I had given my best advice in this situation, only to be rejected as a power-tripping antibiotic extremist.  I had one eye out for an ambush.

What if we ask ourselves more often, both as patients and physicians, “What am I looking for?”  Could we identify biases and fears more readily, and then challenge them?  Would it make asking for and getting what we need a little easier?  What do you think?