Whole Physician Health: Standing at the Precipice

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I published the post below two years ago, and all of it applies even more so today. This week I presented to my department chairs and hospital administration leaders on the importance of addressing physician burnout and well-being. There is a growing sense of urgency around this, some even starting to call it a crisis.

Still, I feel hopeful. Darkest before the dawn, right? Reveal it to heal it, my wise friend says. Physician burnout research has exposed and dissected the problem for 20 years, and now we shift our attention toward solutions.

I will attend the American Conference on Physician Health and the CENTILE Conference next month. I cannot wait to commune with my tribe again, explore and learn, and return to my home institution with tools to build our own program of Whole Physician Health. While we focus on physician health in its own right, we must always remember that it can never be achieved without strong, tight, and fierce connections with all of our fellow caregivers. When we attain this, all of us, especially our patients, are elevated and healed.

Onward, my friends. More to come soon.

*** *** ***

Ever since my presentation to the American College of Surgeons earlier this month on personal resilience in a medical career, I cannot shake the feeling that we need to do more of this work. Physicians from different fields need to talk more to one another, share experiences, and reconnect. We also need to include other members of the care team as equals, and let go the hierarchical thinking that has far outlived its usefulness.

I do not suggest that physicians, nurses, therapists, pharmacists and others should play interchangeable roles in the care of patients. Rather, similar to the central tenet of gender equality, the unique contributions of each team member need to be respected equally for their own merits and importance. As a primary care internist, I must admit that I have seen my professional world through a rather narrow lens until now. I confess that I live at Stage 3, according to David Logan and colleagues’ definition of Tribal Leadership and culture. The mantra for this stage of tribal culture, according to Logan et al, is “I’m great, and you’re not.” Or in my words, “I’m great; you suck.”

“I’m a primary care doctor and I am awesome. I am the true caregiver. I sit with my patients through their hardest life trials, and I know them better than anyone. I am on the front line, I deal with everything! And yet, nobody values me because ‘all’ I do is sit around and think. My work generates only enough money to keep the lights on (what is up with that, anyway?); it’s the surgeons and interventionalists who bring in the big bucks — they are the darlings of the hospital, even though they don’t really know my patients as people…” It’s a bizarre mixture of pride and whining, and any person or group can manifest it.

Earlier this fall, Joy Behar of TV’s “The View” made an offhand comment about Miss Colorado, Kelley Johnson, a nurse, wearing ‘a doctor’s stethoscope,’ during her monologue at the Miss America pageant. We all watched as the media shredded the show and its hosts for apparently degrading nurses. What distressed me most was the nurses vs. doctors war that ensued on social media. Nurses started posting how they, not doctors, are who really care for patients and save lives. Doctors, mostly privately, fumed at the grandiosity and perceived arrogance of these posts. It all boiled down to, “We’re great, they suck. We’re more important, look at us, not them.” The whole situation only served to further fracture an already cracked relationship between doctors and nurses, all because of a few mindless words.

It’s worth considering for a moment, though. Why would nurses get so instantly and violently offended by what was obviously an unscripted, ignorant comment by a daytime talk show host? It cannot be the first time one of them has said something thoughtlessly. What makes any of us react in rage to someone’s unintentional words? It’s usually when the words chafe a raw emotional nerve. “A doctor’s stethoscope.” The implicit accusation here is that nurses are not worthy of using doctors’ instruments. And it triggered such ferocious wrath because so many nurses feel that they are treated this way, that they are seen as inferior, subordinate, unworthy. Internists feel it as compared to surgeons. None would likely ever admit to feeling this way, consciously, at least. But if we are honest with ourselves, we know that we all have that secret gremlin deep inside, who continually questions, no matter how outwardly successful or inwardly confident we may be, whether we are truly worthy to be here. And when someone speaks directly to it, like Joy Behar did, watch out, because that little gremlin will rage, Incredible Hulk-style.

I see so many similarities to the gender debate here. As women, in our conscious minds, we know our worth and our contribution. We know we have an equal right to our roles in civilization. And, at this point in our collective human history, we feel the need to defend those roles, to fight for their visibility and validity. More and more people now recognize that women need men to speak up for gender equality, that it’s not ‘just a women’s issue,’ but rather a human issue, and that all of us will live better, more wholly, when all of us are treated with equal respect and opportunity. The UN’s He for She initiative embodies this ideal.

It’s no different in medicine. At this point in our collective professional history, physician-nurse and other hierarchies still define many of our relationships and operational structures. It’s not all bad, and we have made great progress toward interdisciplinary team care. But the stethoscope firestorm shows that we still have a long way to go. At the CENTILE conference I attended last week, I hate to admit that I was a little surprised and incredulous to see inspiring and groundbreaking research presented by nurses. I have always thought of myself as having the utmost respect for nurses — my mom, my hero, is a nurse. The ICU and inpatient nurses saved me time and again during my intern year, when I had no idea what I was doing. And I depended on them to watch over my patients when I became an attending. But I still harbored an insidious bias that nurses are not scholarly, that they do not (or cannot?) participate in the ‘higher’ academic pursuits of medicine. I stand profoundly humbled, and I am grateful. From now on I will advocate for nurses to participate in academic medicine’s highest activities, seek their contributions in the literature, and voice my support out loud for their important roles in our healthcare system.

We need more conferences like this, more forums in which to share openly all of our strengths and accomplishments. We need to Dream Big Together, to stop comparing and competing, and get in the mud together, to cultivate this vast garden of health and well-being for all. I’ll bring my shovel, you bring your hose, someone else has seeds, another, the soil, and still others, the fertilizer and everything else we will need for the garden to flourish. We all matter, and we all have a unique role to play. Nobody is more important than anyone else, and nobody can do it alone.

We need to take turns leading and following. That is how a cooperative tribe works best. It’s exhausting work, challenging social norms and moving a culture upward. And we simply have to; it’s the right thing to do.

The Primal Fear of Overachievers

Not. Good. Enough.
The driver of overachievers to overachieve.
At some point the overachiever realizes how much they have accomplished.
I’m kinda awesome.
But it’s always overshadowed by
I’m Not Enough.
More overachieving.
I’m pretty awesome.
Still not enough.
More achieving.
Fuck, I am the shit.
And Still. Not. Enough.
Hopefully the realization of this dichotomy sets in–two sides of the same coin–so awesome and not enough.
So how to reconcile?
Reach out.
Connect with other Awesomes.
We are all enough.
Let something else drive the awesomeness, something other than running from not enough.
Be a contribution.
Collaborate, synergize with fellow Awesomes.
Then it doesn’t matter how awesome you are alone because all of your awesomeness just goes into the pot to make the whole greater than the sum of its parts.
Awesomes hold each other up, expecting only that we will each bring our authentic selves to the table to share–nothing more, nothing less.
The only objectives are to participate, exchange, connect, explore, grow, and radiate awesomeness to make the world better for having communed.
We are enough.
Even if we don’t believe it all the time.
Put that fear in its place. It’s not allowed to drive anymore.

Applying the Wisdom of Atticus Finch

Atticus_and_Tom_Robinson_in_court

“You never really understand a person until you consider things from his point of view—until you climb into his skin and walk around in it.”

–Atticus Finch

To Kill a Mockingbird, by Harper Lee

 

How do you practice and achieve empathy?  How do you notice others doing it?

It’s been on my mind a lot these last two weeks.  Current American politics resembles an interminable abscess, oozing ever more copious and putrid gobs of pus, from ever more unforeseen tracts of deep, diseased tissue.  How can we find any Healing Connection in the midst of all this?

Here’s my answer:  Role play and storytelling.

Role Playing Game Males Lego Duplo Play Build

 

Role Play for the Good

I used to hate role play, and now I jump at any chance to try it!  It all changed through a 7 week teaching workshop I did during my chief resident year, and I am forever grateful for the experience.  Now I regularly use role play to teach motivational interviewing, or MI, to medical students and residents.  Put simply, MI is a counseling technique that focuses on patient autonomy, and aims to reinforce intrinsic motivation for change.  My teaching method has evolved over time, due to my own unexpected experience of ‘climbing into the skin’ of others.

In the beginning I used to play the patient, letting students take turns practicing their MI skills on me.  After a couple of sessions I realized that even though I was pretending, I really felt like the students were earnestly trying to help me change my health habits, or making me feel bad about myself, depending on their proficiency.  So to give them the benefit of this perspective, I had them take turns playing both patient and physician.  The feedback revealed a richer, more insightful experience for all.

In 2015 I attended the Active Lives conference, where my technique was further enlightened.  I got to role play four times with a partner: first as patient, then physician, doing it the ‘wrong’ way (directive, authoritative, confrontational), and again in both roles doing it the ‘right’ way (collaborative, empathetic, nonjudgmental).  I felt the immediate contrast of the four roles emotionally and viscerally.  When all I heard from the doctor was, “Yes, I know you’re busy, but you have to find time to exercise,” and “Why don’t you do this…” and, “You should… You need to… If you don’t, then…” I felt absolutely no impetus to take any of this advice.  But questions like, “How important is it to you to…  How confident are you to… What would it take…what would need to happen in order for you to…” and, “What would life be like if…” invited me to explore possibilities, helped me to imagine and create my own future.  As an authoritative physician, I felt frustrated at my patient’s resistance to my evidence-based and well-intentioned advice.  By contrast, as a collaborative doctor, I feel freed to embark on an improvisational Yes, And adventure to reveal each patient’s personal path to healthier habits.  Now I offer my students the opportunity to experience all four roles.

I remembered this insight evolution last week when I came across a 1970 video of Jane Elliott’s classroom racism experiment.  She divides the class by eye color, asserts that blue-eyed children are better than brown-eyed children on one day, then reverses the premise the next.  While she makes privilege assignments that likely would not fly today, she also debriefs with the kids, helping them identify their assumptions, feelings, actions and reactions—much more authentically and directly than I think we are willing to do today.  She does it all without judging or shaming, pointing out biases and encouraging her students to examine them for themselves.  I admire her for pioneering this exercise, and I bet it affected her students in profound and lasting ways.

storytelling

 

The Importance of Story

Clearly, we cannot possibly depend on such academic practices to develop everyday empathy.  Luckily we now have infinitely easier access to one another’s stories than ever before, which is the next best thing.   Lately I feel a keen new appreciation of the importance of storytelling for conveying experience and stimulating mutual understanding.  Obligingly, the universe (read Facebook) has provided me with numerous testimonies of my fellow humans’ experiences and conditions, and this week they touch me even more acutely.  Here are some of them:

  • Former white supremacists talk about the importance of upholding others’ humanity, even as we denounce their beliefs.
  • A black writer recounts multiple instances of racism over her lifetime, inviting her white high school classmate to imagine and consider how they exemplify his white male privilege.
  • The head of neurosurgery at the Mayo Clinic in Florida tells his story of illegal, then legal immigration, and a subsequent life dream realized.
  • Neil DeGrasse Tyson shares stories of genitals on fire, educators’ responsibility to the electorate, pressure from his black classmate to contribute to ‘the black cause,’ realizing that he is doing just that, and why he wants to be buried instead of cremated (he has changed my mind, by the way).
  • David Duke’s godson credits the college friends who welcomed him despite his pedigree, with helping him defy and shed it.

 

What’s the Point?

The overarching goal here is to intentionally thwart the abstraction and dehumanization of people who are different from ourselves.  Stepping into another person’s shoes, ‘climbing into (their) skin,’ imagining how they feel, and actually feeling it—this is the best protection against bias, prejudice, and discrimination.  Empathy forms the sticky webs of connection that stymie the hymenoptera of hatred mid-flight, or catch us in the face and remind us to look where we’re going.  Where do we want our thoughts, words, actions, and relationships to take us?

I imagine a world of colorfully flawed humans, who acknowledge our biases openly and honestly; who recognize the risks that those biases carry; who accept ourselves, warts on soles and souls and all; who commit to a lifetime of extending that acceptance to one another; and who understand that it is our relationships, all of them, that kill us or save us.

So let’s play and tell—and feel and listen.  Really,  it’ll be good for all of us.

 

Only Love Can Win

Lily Pad Lake trail weather coming

Holy hell, what a week.  How are you feeling?  Most people I know express some combination of shock, resignation, rage, disbelief, hopelessness, gloom, and resentment.  I’m trying hard to practice Radical Acceptance.  It’s similar to the second arrow principle, in that at the very least, it lessens my own suffering from our collective circumstance.  But more than that, it allows me to focus more on what I will do, than seethe around my negative reactions.

I’m thinking of the Twitter account named Yes, You’re Racist.  Apparently the owner wants to identify the white supremacists who marched in Charlottesville, to publicly shame them and possibly get them fired from work. At least one person has lost his job based on a photo posted to the account.  What do you think about this?  I admit, my first reaction was positive.  Yes, call them out, make them accountable, I thought.  But then I wonder what good will this do?  Will the guy who got fired from the hot dog place suddenly think it was morally wrong to attend the march?  Or will he interpret his employer’s action as further proof that the liberal left conspires to restrict free speech and assembly, thereby deepening his animosity toward anyone who opposes his views from the left?  Will it open any space in his mind to consider why white supremacy is wrong, or help him acquire empathy or compassion toward any marginalized group?  Or won’t it just drive his racist expressions underground?  Doesn’t public shaming like this run the risk of re-closeting these people, so their grievances foment in the dark, only to be released again under pressure, in some act of overt violence?

I think about the fights between marchers and anti-protestors—between those who wish to incite violence, and those who succumb to the provocation.  To be clear, the Neo-Nazi, white supremacist marchers who descended on Charlottesville represent a vile and unacceptable set of ideas.  They are the villains.  And, fighting violence with violence is never a good solution.

So, we ask, what can we do?  How do we respond?  Maybe it’s because I’m on vacation this week, communing with nature in the mountains and watching the annual Perseid meteor shower from 10,000 feet, on a clear, literally stellar night, surrounded and awed by our millennia-old universe.  It keeps me from stalking Facebook quite so many hours a day, and gives good perspective.  I feel somehow more capable of saying, This is how things are.  It sucks.  It’s wrong.  And I can still make a difference.

In the end, I believe Only Love Can Win.  Blaming, shaming, belittling, and otherwise demeaning people for certain beliefs, actions, or associations—hating them—does not help.  What does help is offering compassion and empathy, and listening to understand.  I know I have said and written it many times, and I know many will argue that now is not the time to ‘get soft.’  But believe me, practicing love in the face of hate is anything but soft.  Let me share some resources that illustrate this, and that hold me up.  This is a very long post, and I hope you will stick with me ‘til the end.

Ai

Agape Love

Maria Popova, curator of the illuminating blog Brain Pickings, inspires me with her summary of Dr. Martin Luther King’s 1958 essay “An Experiment in Love.”  I refer to this article often since January 20.  Dr. King explores six tenets of nonviolent resistance (below).  It reminds me that while I vehemently oppose bigotry, racism, sexism, misogyny, xenophobia, and fascism, I can do it with a peaceful heart, full of love for humanity, and with faith that even my small contribution of said love can make a difference.  Here are the highlights of her piece, MLK’s words quoted:

  1. Nonviolent resistance is not passive cowardice. “For while the nonviolent resister is passive in the sense that he is not physically aggressive toward his opponent, his mind and his emotions are always active, constantly seeking to persuade his opponent that he is wrong. The method is passive physically but strongly active spiritually. It is not passive non-resistance to evil, it is active nonviolent resistance to evil.”
  2. The goal is connection. “Nonviolence … does not seek to defeat or humiliate the opponent, but to win his friendship and understanding. The nonviolent resister must often express his protest through noncooperation or boycotts, but he realizes that these are not ends themselves; they are merely means to awaken a sense of moral shame in the opponent. The end is redemption and reconciliation. The aftermath of nonviolence is the creation of the beloved community, while the aftermath of violence is tragic bitterness.”
  3. Separate the people from problem (as William Ury et al would say). “The attack is directed against forces of evil rather than against persons who happen to be doing the evil. It is the evil that the nonviolent resister seeks to defeat, not the persons victimized by the evil… [Regarding racial injustice:] We are out to defeat injustice and not white persons who may be unjust.”
  4. Be prepared to pay the cost. “The nonviolent resister is willing to accept violence if necessary, but never to inflict it. He does not seek to dodge jail.”
  5. Manage thyself. Do not allow yourself to descend to the depths of hate while you fight hate itself.  Cultivate love instead.  “The nonviolent resister not only refuses to shoot his opponent but he also refuses to hate him. At the center of nonviolence stands the principle of love…To retaliate in kind would do nothing but intensify the existence of hate in the universe. Along the way of life, someone must have sense enough and morality enough to cut off the chain of hate. This can only be done by projecting the ethic of love to the center of our lives.  This is Agape love…  Agape means understanding, redeeming good will for all men. It is an overflowing love which is purely spontaneous, unmotivated, groundless, and creative… Another basic point about agape is that it springs from the need of the other person… The Negro must love the white man, because the white man needs his love to remove his tensions, insecurities, and fears… Agape is not a weak, passive love. It is love in action… Agape is a willingness to go to any length to restore community… It is a willingness to forgive, not seven times, but seventy times seven to restore community.”
  6. Hope.  “Nonviolent resistance … is based on the conviction that the universe is on the side of justice. Consequently, the believer in nonviolence has deep faith in the future. This faith is another reason why the nonviolent resister can accept suffering without retaliation. For he knows that in his struggle for justice he has cosmic companionship.”

moths on poop

10 Ways to Fight Hate

One of the first pieces I read after the events on Saturday was this article from the Southern Poverty Law Center, listing ten ways to fight hate.  So while I carry that peaceful heart full of Agape love, these are the concrete things I can do right now (highlights quoted):

“The good news is, all over the country people are fighting hate, standing up to promote tolerance and inclusion. More often than not, when hate flares up, good people rise up against it — often in greater numbers and with stronger voices.”

  1. Act
  2. Join Forces
  3. Support the Victims
  4. Speak Up

“Do not debate hate group members in conflict-driven forums. Instead, speak up in ways that draw attention away from hate, toward unity.

“Goodness has a First Amendment right, too. We urge you to denounce hate groups and hate crimes and to spread the truth about hate’s threat to a pluralistic society. An informed and unified community is the best defense against hate.

“You can spread tolerance through social media and websites, church bulletins, door-to-door fliers, letters to the editor, and print advertisements. Hate shrivels under strong light. Beneath their neo-Nazi exteriors, hatemongers are cowards and are surprisingly subject to public pressure and ostracism.

  1. Educate Yourself

“Most hate crimes…are not committed by members of hate groups; the Southern Poverty Law Center estimates fewer than 5 percent. Many hate crimes are committed by young males acting alone or in small groups, often for thrills. While these perpetrators may act independently, they are sometimes influenced by the dehumanizing rhetoric and propaganda of hate groups.”

  1. Create An Alternative

“Do not attend a hate rally. As much as you might like to physically show your opposition to hate, confrontations serve only the perpetrators. They also burden law enforcement with protecting hatemongers from otherwise law-abiding citizens. If an event featuring a hate group, avowed separatist or extremist is coming to your college campus, hold a unity rally on a different part of campus. Invite campus clubs, sororities, fraternities and athletic organizations to support your efforts.

“Every act of hatred should be met with an act of love and unity. Many communities facing a hate group rally have held alternative events at the same hour, some distance away, emphasizing strength in community and diversity. They have included forums, parades, and unity fairs featuring speakers, food, music, exhibits, and entertainment. These events give people a safe outlet for the frustration and anger they want to vent. As a woman at a Spokane, Washington, human rights rally put it, “Being passive is something I don’t want to do. I need to make some kind of commitment to human rights.”

  1. Pressure Leaders

Form relationships with community leaders before a hate incident occurs.

Encourage leaders to name the problem.

Push leaders when they show bias or fail to act. [And do it respectfully—ad hominem never helps.]

  1. Stay Engaged
  2. Teach Acceptance

“Bias is learned in childhood. By age 3, children can be aware of racial differences and may have the perception that ‘white’ is desirable. By age 12, they can hold stereotypes about ethnic, racial, and religious groups, or LGBT people. Because stereotypes underlie hate, and because almost half of all hate crimes are committed by young men under 20, tolerance education is critical.”

  1. Dig Deeper

“Look inside yourself for biases and stereotypes.

“We all grow up with prejudices. Acknowledging them — and working through them — can be a scary and difficult process. It’s also one of the most important steps toward breaking down the walls of silence that allow intolerance to grow. Luckily, we all possess the power to overcome our ignorance and fear, and to influence our children, peers, and communities.”

VICE screenshot

Breathe Deep, Stay on the Path, and Engage

How would you confront a white supremacist in person, face to face?  Would you share a meal with him/her?  I saw this video clip on Facebook, of a young Chinese-American man, Eddie Huang, sitting down to dinner with Jared Taylor, an older, white nationalist man, and founder of American Renaissance, to discuss Taylor’s perspective.  The American Renaissance site espouses genetic differences in intelligence and the propensity to commit crimes between races, among other things.  Taylor states that historically, Europeans have “killed more people per capita” than any other group, and attributes this to them being “more technologically advanced.”  He voted for 45 because his policies would “slow the dispossession of whites in America.”  He says he wants to keep whites a majority in the United States, or else they “no longer control our own destiny.”

I imagined myself in Eddie’s shoes, and I could not fathom how I could stomach this conversation while eating.  Actually I think he stops, while Taylor continues to eat—Chinese food.  I don’t know anything about Eddie Huang other than what I see in this video, and I admire him.  He sits down and engages respectfully, thoughtfully, and firmly, with a person who basically thinks he does not deserve to be an American.  Could you do that?  I’m not sure I could.  And what would the world be like if we all trained to do exactly this?

Thank you for reading to the end.  My point here is that we can oppose and resist more effectively than with rage, shame, and violence.  I know I won’t make everybody put down their clubs and fists with my small words, but this is where I stand, and I commit to speaking my stance as much and as loudly as possible.  I pledge to do my best always to profess what I am for, more than what I am against.  I commit to a practice of Agape love, Radical Acceptance, Mindfulness, and Peaceful, Respectful Activism.  I would love your company on this journey.

 

Resistors In Series

Estes 2011

As nerd stuff goes, biology has always been more my speed than physics.  When my group in AP bio got to dissect a fresh frozen elk heart instead of a preserved sheep heart, I was positively overjoyed.  I remember so clearly the size (almost as big as my head) and weight of it, the texture of the muscle.  I can still see the valves, the heartstrings, and coagulated blood in the right and left atria.  So it kind of surprised me when I thought of a physics metaphor for our politics today.  I, the daughter of a PhD in applied mechanics, earned the lowest grade of my college career in first quarter physics.

Like many science nerd adolescents of the 80’s, I looked forward to new episodes of “MacGyver” every week.  The handsome, mullet-sporting Richard Dean Anderson always jerry-rigged his way out of life-threatening situations using everyday chemistry and such.  How fun that my kids can now enjoy the same drama with the CBS “MacGyver” reboot, starring Lucas Till.  We bond over TV, my kids and I.

macgyver white board

In the “Chisel” episode, Mac and his team find themselves barricaded inside a US Embassy, under attack by terrorists.  On a white board, he calculates how many inches of paper to place in front of the windows to stop incoming machine gun bullets—it’s 8 in this case.  [As an aside, the Mythbusters showed that paper is a plausible form of body armor.]  This got me thinking: one sheet of paper, so thin and flimsy, is easily shredded.  But layered in redundance, it can stop a barrage of deadly bullets.  It feels a lot like our national political activism since last November.

Women, scientists, environmentalists, educators, people of color, the LGBTQ community, Native Americans, writers, actors, physicians, patients, religious groups, law enforcement, legislators, and the press—We have all found our legs and our voices; we have stood and proclaimed not only our opposition to 45, but our commitment to our core values of inclusion, equality, respect for the planet, and respect for one another.  I submit that we are resistors in series.

resistors in seriesYou may recall from physics class that when resistors are placed end to end in an electrical circuit, their total resistance is the sum of their individual impedance units.  As the current passes through one resistor, it encounters the next one, and the next, one after another, slowing its progress.  I like to see today’s activist groups in this way, each contributing several layers to the dense, thick paper barricade at the windows of democracy as we know it, defending it against attack.  And the more we can stand united, supporting one another, the stronger we will be.  Could our resistance even be exponential, rather than simply additive?

Tyrants and authoritarians divide to conquer–they like resistors in parallel, where the total impedance is actually a fraction of each individual unit’s resistance.  By pitting each group against every other, a despot can trample them each/all with ease, and they might never see it coming—the same voltage directed across multiple, isolated resistors transforms them into conductors of the oppressor’s will.resistors in parallel

Perhaps this was our orientation prior to the last election.  We each had our pet causes, for which we felt varying degrees of personal activism.  We saw ourselves as detached, benignly unconnected.  But as we have witnessed a progressive threat marching against everything that we care about, a shared, collective threat, a new current has sparked.  Perhaps this mutual unease has reorganized us to connect in succession, to close ranks.

I was reminded of this idea when I read this piece by Charles M. Blow in the New York Times.  He posits that “America regularly experiences bouts of regression, but fortunately, it is in those regressive periods that some of our greatest movements and greatest voices… found their footing.”  Then I came across another article from The Atlantic, suggesting that even our legislators may be reorienting themselves into more serial, additive connectedness:

In hindsight, the Democrats’ decision to not allow partisanship to subsume collegiality or compassion, to cheer McCain along with their Republican colleagues, to embrace a friend even as he cast a decisive vote to move forward with a bill they despised, no longer seems naive. “I hope we can again rely on humility, on our need to cooperate, on our dependence on each other to learn how to trust each other again and by so doing better serve the people who elected us,” McCain had said in his speech.  

Had Democrats met that vote by attacking McCain, he might not have voted no [on the Senate’s ‘skinny repeal’ of the Affordable Care Act] last night. He might not have been so immune to the entreaties of his colleagues. He might not have resisted the arm-twisting of the president who never spent a day in public service before winning an election, who mocked him so cruelly two years ago. He might have decided against casting a vote to derail his own party’s seven-year crusade to dismantle the Affordable Care Act, a goal he still endorses.

I know my analogy vastly oversimplifies our political landscape.  Still, it comforts me.  I feel particularly focused on healthcare today, and I like to think that even if healthcare is not someone else’s chief concern, she will stand up with me when our healthcare system is under attack, just like I will rise with her in defense of our natural treasures, etc.  We stand, shoulder to shoulder, hand in hand, to resist and defend.  This vision of unity and cohesion is my hope and aspiration, not just now, but for generations to come.

Love You Into Being

IMG_4550

A couple of weeks ago I met my new medical students.  These 10-12 trainees will be my small group for the next two years.  We will meet monthly to discuss the soft stuff of medical training—hierarchy, tribalism, death and dying, medical errors, difficult patients, etc.  Some call it “third year medical student support group.”  This is my 6th year of the pleasure and privilege (I inherited my first group halfway through, when their previous preceptor moved out of state).

With each successive group I am ever more amazed at the students’ level of insight.  They articulate compassion, humility, and maturity that I don’t think I had at their level of training. Or maybe it’s because we did not have classes like this to explore such things when I came up (or maybe I don’t remember?).  More and I more I see my role as facilitator more than teacher.  I am not here to impart medical knowledge.  Rather, it is my job to stimulate exploration, conversation, and meaning.  It’s so freeing, really—there is no standardized test to teach to.  And yet I see it as my responsibility to help prepare these gifted young people to face the greatest challenge and reward of the profession: human relationships.

I feel no fear or trepidation.  We cannot ‘fail’ at this class, any of us.  Because the point of it is simply for everybody to participate, contribute, consider, and learn—myself included.  Each month the students are given questions to answer in the form of a blog post.  For example, “Recall an example of inspiring or regrettable behavior that you witnessed by a physician.  Describe the situation, and its impact on you, the team, and/or the patient.”  I read them all and facilitate discussion, tying together common themes and asking probing questions.  My primary objective is to help them maintain the thoughtfulness and humanity that led them to medicine in the first place.  Medical training has evolved in the past 20 years, for the better in some ways, not so much in others.  One way we do much better nowadays is recognizing the hidden curriculum, and shining light on its effects, both positive and negative, through classes like this.

We all have those teachers who made a difference in our lives—or at least I hope we all do.  I have multiple: Mrs. Cobb, 4th grade; Mr. Alt, 7th grade math; Ms. Townsend (now Ms. Anna), 7th grade English; Ms. Sanborn, 7th grade social studies; Mrs. Stahlhut, 9th grade geometry; Mrs. Summers, 10th grade English; Coach Knafelc, varsity volleyball; Dr. Woodruff, primary care preceptor; Dr. Roach, intern clinic preceptor; Dr. Tynus, chief resident program director.  My mom is one of these teachers, also.  She leads nursing students in their clinical rotations.  I have seen her student feedback forms—they love her.  And it wasn’t until I heard her talk about her students that I realized why they love her and what makes her so effective—she loves them first.  Teaching is often compared to parenting.  Our parents, at their best, see our potential and love us into our best selves.  They cheer us, support us, redirect us, and admonish us.  They show us the potential rewards of our highest aspirations.  If we’re lucky, they role model their best selves for us to emulate.

All of my best teachers did (do) this for me.  I’m friends with many of them to this day, and I still learn from them in almost every encounter.  I love them because I feel loved by them.  They held space for my ignorance and imperfections.  I always knew that they knew that my best self was more than the last paper I wrote, the last test I aced, or the last patient encounter I botched.  To them, my peers and I were not simply students.  We were fellow humans on a journey of mutual discovery, and they were simply a little farther along on the path.

This is my aspiration as a teacher, to live up to the example of all those who loved me into the best version of myself today.  This kind of love allows for growth and evolution, from student to colleague, to friend, and fellow educator.  This is not something attending physicians typically express to medical students, positive evolution of medical education notwithstanding.  But when I met this new group, I was overcome by love for them.  So I told them.  “If you take away nothing else from our two years together, I want you to have felt loved by me.  I wish to love you into the best doctors you can be.  That is my only job here.”  Or something like that.  It was impulsive and possibly high risk.  But it was the most honest thing I could say in that moment, my most authentic expression of my highest goal for my time with them.  I only get to see them once a month, and I want them to be crystal clear about what I am here to do.  We have lots to cover these two years, so much to learn and apply.  And love is the best thing I can offer to hold us all up through it.

Support for the Inner Work

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Things were a little crazy this week.  I have an idea for a post and still have not sat down to write it out.  But I want to share something that came out on my Facebook page (of course) tonight.  One of the reasons I love writing is that insights pop out when you least expect them.  Writing exchanged with others is even better, because those insights are then shared, and their meaning amplifies.

I posted this article from the Washington Post yesterday: “Nearly half of liberals don’t even like to be around Trump supporters.”  It’s a summary of a recent Pew Research Center survey, which finds that 47% of liberal Democrats “say that if a friend supported Trump, it would actually put a strain on their friendship.”  It posits, among other things, that liberals are less tolerant of dissenting ideas because they are clustered in urban areas, lending to louder echo chambers.  By contrast, only 13% of Republicans answered that “a friend’s support of Hillary Clinton would strain their friendship.”

From the survey report:…Nearly nine months after the election, most people (59%) say it is ‘stressful and frustrating’ to talk about politics with people who have a different opinion of Trump than they do; just 35% find such conversations ‘interesting and informative.'”

I consider myself a socially heavily left-leaning, fiscally centrist Independent, but I identify more with liberals than conservatives, by a large margin.  This article made me sad, that my ‘tribe’ shows itself to be much more intolerant and judgmental than I would like.

I posted this comment along with the article:

Ooohh, so much data here, so much potential for blame, and also for self-exploration. Humbling, no question.
“Be extra kind with your comments on this one please, friends. No need to reopen barely scabbed wounds. I mean for my page to be a safe place for all of us to engage. We are all in it together, and the sooner we *all* figure out how to deal with 45 and one another, the better we will all be.
“Also, I’m bummed that Asians are always left out of the data set.”

I got some comments from my liberal friends about how hard it is to talk to Trump supporters, so much so that they avoid talking politics with those friends altogether.  But one friend exemplified my aspiration for all of us.  She wrote:

“… I recently had dinner with a very close friend who voted for Trump. Typically I think I’m a really good listener, listening with curiosity and a desire to raise the conversation and all involved to a higher level. However, when our conversation turned to politics I found myself cutting her off, getting defensive and bordering on being critical of her. I was horrified by my own behavior. I think this article hits on it – the support or opposition of Trump feels like less of a political stance and more of a statement of a person’s values and morals. I don’t think that’s necessarily true- I think a large population of Trump voters (my friend included) were actually voting against Washington more than for Trump. While I can’t get behind Trump I can get behind a vote to change the system. I wonder what might happen if more of us looked for what we can stand behind together?! Thank you for continuing to be a voice for this movement!”

Exactly!  Immediately I felt connected to my friend in a higher calling, and a shared struggle.  I replied:

“(My dear friend), I derive so much of my strength and curiosity from you. How many of us can own up publicly about our own flaws and failures, like you did here? And I know you know I use the word failure in the most empathetic and loving, mutually understanding way. I think that is the first step–complete humility and openness to our own imperfection. It’s so fucking hard. And I’m so lucky to have friends like you, (these four other dear friends), and others… I know now, better late than never, that we cannot do this work without unwaveringly reliable support, no matter how motivated we are.  And for those of us who are already well-supported, I think it’s our responsibility to look outward and support others. You never know when or where someone may be standing on the edge of openness, and when your small gesture of encouragement may nudge them on. Thank you for your loving support, my soul sister!”

It really is true, we cannot dig deep and bring out our best selves by ourselves.  We are meant to hold one another up and accountable, to bring out the best in each other.  It breaks my heart when I interview patients, and learn how sparse and frail their emotional support networks are.  There is no stereotype for this scenario, it can happen to the best of us.  Past experiences, circumstances, timing, life events—they can all combine to undermine our relationships, thereby weakening our capacity for self-awareness and exploration.  So we fall back on default modes of defensiveness, righteousness, denial, and blame.  Whether it’s quitting smoking, sticking to a healthy eating plan, or elevating our political discourse, we are truly stronger together.

I share this tonight because I so admire my friend for owning her whole self.  I am so grateful to her for sharing her imperfections and vulnerability with humility and hopefulness.  She gives me strength to keep going, despite how fucking hard it is.  And I hope I can do the same for many, many others.