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Love Letter to My MD Classmates

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My first stethoscope, retired now after 29 years.

Congratulations, Pritzker School of Medicine Class of 1999! It’s been 25 years.

Look how far we’ve come! Many of us were babies when we started–in our early 20s, brains not even fully formed, enrolled straight out of college, innocent and arrogant at the same time. Now some of our own children are that exact age, and we look at them hiding knowing smirks. Oh, they’ll learn life in good time, these kids.

Being with so many of you this weekend, some not since we graduated, filled my heart with such expansive warmth and joy. We are all now still who we were then–same smiles, postures, mannerisms, quirks. And we have all definitely ‘matured.’ Some of us now sport lighter hair and heavier bodies. Others, damn you, exhibit no observable physical changes. Our greatest acquisition, however, is our hard-earned wisdom and character–that which can only come with lived experience. Med school was no joke, and residency a trial by fire. We have all witnessed life at its first and last breaths, and among all of us, everything in between. We listen, watch, palpate, percuss, incise, excise, medicate, compress, intubate, ventilate, inject, evacuate, saw, cauterize, staple, and suture. We research, write, present, teach, and lead. We are the experts in our fields. And yet, our age and work have taught us humility, made us reverent, lifelong learners first. As technology accelerates and we increasingly inhabit a world of human creation, with which we are not physiologically equipped to cope, we, the Class of 1999 and our colleagues of other years, persist in our oath to care for our fellow humans to the best of our ability. We commit to Helping however we can, to comforting even when we cannot relieve or cure.

I feel a kind of double vision, seeing us as we were then when I look at us now. The playful comaraderie, the stories, the shop talk–it’s as if no time has gone by–we are still us, Pritzker ’99. This is how deep, bonded belonging feels. How many of us marveled repeatedly this weekend over tacos, drinks, snacks, and dessert at the special-ness of it all? We are a tribe within a tribe, a cluster of diversity unified over time, experience, and age. Differences between and among us in youth feel almost irrelevant now, frictions dissipated, shared memories cemented. Interdisciplinary stereotypes and tensions evaporate among us as classmates. We knew and know one another first as whole people, in the same boat from the outset, rowing together, ever forward. HA! We grew from undifferentiated, pluripotent stem cells into fully functioning end organ tissues, now differentiated and still attuned to one another–like a nascent, then seasoned orchestra playing an ever larger and more complex repertoire.

OH, how I reveled in the hugs, the smiles, the recollections, reflections, and communion, the hopes and plans for future sustained connection. It felt honest and vulnerable, soft and strong, professional and personal–safe–one of you said it felt like coming home. Yes.

*sigh*

I had no idea 25 years ago that it would feel this way now. It’s the best, most heartwarming surprise. I wrote about our 20 year reunion, which I only just now remembered. Clearly, these events move me immediately and deeply, this time even more so than last.

My greatest wish for us all, my dear classmates, is that we may continue bravely, wholeheartedly, generously, joyfully, and humbly, on the mission of our esteemed profession, for many years yet. My greatest hope is that we maintain and tighten our bonds, holding one another up in spirit across the miles and over the coming decades. My greatest joy is that we may stay connected, no matter what happens in our careers and lives.

Peace, love, and light to you all. May our collective affection and bond call forth the best in us, for ourselves, our patients, loved ones, institutions, and all of humanity that we have the privilege to touch.

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?