Tag Archives: communication

#AtoZChallenge: Assumptions and Appreciation

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Welcome to my first attempt at the Blogging A to Z Challenge!  26 posts in April, one for each letter of the alphabet (I get one day off per week).  I will explore meaningful words to apply to perceptions, attitudes, behaviors, and relationships. It’s a personal journey, part of my mission of self-assessment and development through writing.  Thank you for stopping by, and please feel free to comment! 🙂

 

Yoga instructors. Football players.  ER nurses.  Asian college students.  Old white men.

Hold these likenesses in your mind’s eye for a moment. Who do you see?

Was the yoga instructor a man or woman? The football player?  It’s impossible not to make assumptions, to apply stereotypes.  Such constructions help us make sense of the world.  They allow us to move through countless human encounters quickly and automatically.  And, they can limit us far more than we realize.

One spring day my kids and I sat in the car, waiting to exit the parking lot after church. Three men, Caucasian, in their 60s, crossed in front of us.  They were well-groomed and overweight—grandpas, likely.  Their expressions were neutral, absorbed in conversation.  One of them looked a little winded from walking.  They were perfectly unremarkable, and they did not notice us.

I felt an acute flash of fear.  It was visceral, as if, at any moment, they could decide that my kids and I were not worthy of being at that intersection, and that they somehow had the power to impact my life in ways that I could not control or influence.  Three apparently unassuming white men.   Fascinating.

I remembered this story when a friend and colleague recently shared this blog post on our assumptions about surgeons.  I realized that despite being married to a surgeon, having multiple surgeon friends, and trying every day to live with an open mind, I still ascribe to the stereotype of the mean surgeon.  It comes out when I hang up the phone after a pleasant conversation with an ENT fellow.  “Wow, he was so nice,” I think, surprised.  Or when I feel righteously annoyed after a terse and condescending interaction with his attending.  “What do you expect,” I say to myself, “he’s a(n old, white, male) surgeon.”  Nobody would ever say that about a pediatrician.

I don’t shame myself for harboring the mean surgeon and old white men stereotypes. They were born of a certain reality and make me appropriately cautious in new situations.  I don’t think I behave badly because of them, and I readily acknowledge when the stereotypes are broken.  But the realization that I hold these assumptions so deeply—subconsciously—gives me pause.  What other assumptions do I carry, and how do they limit my relationships?  I think it’s fair to say that we all carry shards of racism, classism, and other forms of blatant prejudice.  Here’s what I also think:  It’s okay.  We can’t help it, that’s just how it is.  Denying it just makes it that much more insidious, subversive, and toxic.  I’m prejudiced, you’re prejudiced, we’re all prejudiced.  The more we say it, the less scary it gets.  The first step is acknowledgement without shame.

But we cannot, and must not, stop there. We can’t only say, “We can’t help it, that’s just how it is.”  We must take the next step, which is to manage it better.

I think an excellent antidote to toxic assumptions is appreciation.

Dictionary.com includes the following definitions of appreciate:

  1. To regard highly; place high estimate on: to appreciate good wine.
  2. To be fully conscious of; be aware of/ detect: to appreciate the dangers of the situation.

Let us first fully appreciate (be aware of/detect) the scope of our prejudices: Their cultural, familial, or experiential origins, their subtle influence on our perceptions, and the covert ways they manipulate our thoughts, words, and actions toward others.  Awareness is key.  It is also hard.  It’s hard because we know we shouldn’t be prejudiced, it’s bad.  Prejudiced people are bad, they do bad things, we don’t want to be like them; if we admit our prejudices then that means we are bad, that we are not worthy.  STOP.  The only way to keep from acting on our negative stereotypes and perpetuating racism and xenophobia is to fully acknowledge their existence and confront them, head on.  They do not define us.  They are not all of who we are and what we stand for.  Their presence does not negate all that is good, generous, and inclusive about us.  AND, they are part of us.  We cannot escape them by way of denial.  If we can call ourselves out honestly, lovingly, and with forgiveness, we can then integrate our prejudices, and put them in their place.  Appreciation does not mean approval of, or abject subjugation by, our biases.  It is simply the first step to living wholly, to knowing and owning all of ourselves, and moving with intention and mindfulness.

Then, let us apply the other definition of appreciation to others. Let us regard more highly those whom we may automatically, however subtly, belittle in our subconscious.  How might we do this?  Look for that which we share.  She is a mom.  She must love her kids as much as I love mine.  What are their circumstances, what lessons is she trying to teach them, and what would I do in her place?  Why did he become a doctor?  He must want to help people like I do.  I could never do what he does, so high risk, so much responsibility.  God bless him, we need people like him.

Let us then solidify the process with words, out loud. “I can tell you really love your son.”  “Thank you for caring so much about our patient.”  It may sound trite, even silly, at first.  But we can never underestimate the impact of a few kind words, not just on others, but on ourselves.  When I acknowledge myself in you, I make a connection.  I see you, I recognize you, I appreciate you, as I do myself.  Prejudice thrives in silence and denial.  It cannot long survive being spoken out loud and it certainly withers in the presence of true connection.

We will always make assumptions.  Tempered with some well-placed appreciation, though, perhaps we can get through life with a little more love and a little less suffering.

So You Want to Lose Weight: The Four A’s of Goal Setting

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“I need to lose 20 pounds,” says Peter. “All of my doctors have told me this.”  His blood sugar, blood pressure, and cholesterol are all elevated again, this time while still on medication for the latter two.  Diabetes, hypertension, and stroke all run in Peter’s family, and at age 57, he wonders which will get him first.  He knows he’s overweight.  He feels fat, stiff, sluggish, and old—as if someone wound his body clock ahead twenty years without asking.  He really doesn’t want to add any more medication.  I know exactly what his doctors think:  ‘Then you have a lot of work to do!’  We know he did not get here overnight.  His weight is the cumulative result of years of dysfunctional patterns:  Indiscriminate eating, sleep deprivation, and disproportionately high work stress, among others.  Aberrations in glucose, blood pressure, and cholesterol all increased with weight, parallel outcomes of longstanding habits.  We doctors all know this, but it takes too long to talk to patients in detail about nutrition, sleep, stress, and physical activity (or so we think).  We assume they know what to do when we say, “Lose 20 pounds.”  But is this really helpful?  How else can we help our patients move toward their healthier selves?

We set weight loss goals all the time, all of us—physicians included. We choose a number on the scale—an outcome—that represents our better selves, however we see it.  I suggest today that behavior-oriented goals, rather than outcomes-oriented ones, lead to far greater and more meaningful success.  How much are we really in control of what we weigh, day to day?  Sleep deprivation and dehydration disrupt regulatory mechanisms of hunger and satiety. Stress alters metabolism in myriad ways, not to mention often causing more sleep deprivation—a dangerous downward spiral. Knowing this, and recognizing the pressures and stressors we all face every day, how could we physicians make our advice a little more relevant?  I present to you my Four A’s of Goal Setting:

 

1. Assess-ability

“I want to lose 20 pounds by April 15.”

A weight loss goal cannot be fully assessed until the designated endpoint—it is a lagging indicator.  I get no feedback on my progress until I arrive, and then it’s too late to do anything about the result.  Even if I weigh myself in the interim, how do I interpret the information?  A couple days of constipation and a few salty meals can spike my heft in alarming ways on any given morning.  I feel bad about myself when my weight goes up; I’m happy if it’s coming down.  But I’m not exactly sure what’s happening—I cannot accurately assess the situation.

Alternatively:  “I need to exercise 3 times a week, starting on Sundays.” And, I get to define what “exercise” means:  Walk an extra 1000 steps, do two circuits of the 7 Minute Workout, spend 20 minutes on the elliptical, or whatever!  This goal can be easily assessed instantly, anywhere, anytime.  It’s Thursday morning.  Have I worked out three times this week?  How many days of the week are left to achieve this goal?  Which days will I most likely be able to do this?  Now I can make a clear and concrete plan.

Mark, like Peter, is overweight, sedentary, and motivated to make some changes. He has recently started walking one mile, 3 days per week.  He also wants to change his eating, but doesn’t know where to start.  I suggest logging his food with an app such as My Fitness Pal (I have no financial or other interests in their business or in 7 Minute Workout).  He inputs his weight, height, and overall activity level, newly elevated to “lightly active.” He also enters his weight goal: lose 0.5 pound per week.  The program calculates his daily calorie goal, and each time he logs a meal, he can see exactly where he stands.  The app helps him keep track of progress, objectively, in both the short and long term.  Science tells us that feedback—the more frequent and specific, the better—boosts and maintains motivation.  The more easily Mark can assess his status toward achieving his goal (staying within his daily calorie limit), the more likely he will stay the course.

 

2. Actionability

Outcome goals do not elicit action.  “Lose weight.”  This statement is too vague—it cannot be acted upon. It doesn’t tell me what I need to do.  Furthermore, once I have ‘lost weight,’ what do I do then?  How did I get here, and how do I continue?  “Maintain the weight loss.”  How?  Focusing our gaze on the distant endpoint often leads to meandering, or worse, standing still.  I do not suggest ignoring the outcome or invalidating it, but rather paying attention to the practices that will get us there, rather than just talking about being there already.  Setting goals as actions or behaviors—doing specific things—lays out the steps to take toward a desire outcome.  Action leads to self-efficacy and empowerment.

Peter asks himself, ‘What needs to happen in order for me to lose 20 pounds?’ He makes this list:

  • Limit fast food to once a week. Assess-ability check: It’s Friday morning. Have I already had McDonald’s this week? Yes? Salad bar it is. No? Ooo, opportunity: Maybe I can resist today and tomorrow and exceed my goal! Empowerment city, here I come!
  • Move more. Assess-ability check: Have I moved more this week? Ummmm…How do I know? Revision: Get on the treadmill for 45 minutes, four times a week. Check.
  • Get to bed by 10pm every night. Assess-ability checks out here, too.

 

3. Attainability

Are Peter’s goals realistic? How likely is he to accomplish these three behaviors?  He and his doctors all feel a sense of urgency to get control of his situation.  Society also has a way of pressuring us to go ‘all in.’  Like if we’re not all in the gym 5 times a week for an hour of intense cardio and free weights, we’re just not doing enough, so why bother?  All of these factors can push us to set lofty, unattainable goals, thereby setting ourselves up to fail.

Peter, an older single dad, works 12 hour days. He prioritizes his three daughters, who often need help with homework and want to talk at night.  Looking over his action-oriented goals list again, a few adjustments become necessary:  Change treadmill to twice a week, for 20 minutes.  When it comes to exercise, anything is better than nothing!  He had not noticed the anxiety lurking in his chest as soon as he had said “45 minutes, four times a week.”  Now he feels relief and enthusiasm, rather than dread.  He also realizes that as busy season at work approaches, late nights will be inevitable. Getting to bed by 11:00pm at least on weekends, and maybe one more night a week, is more realistic.

These revised targets are what Daniel Pink might call “Goldilocks” goals.  Not too easy, not too hard.  Peter will have to stretch some weeks to achieve them.  But they lie within reach, if just barely.  Regular successes will strengthen the new routines and keep him motivated.  Over time, as he feels more effective, he may set progressively demanding behaviors to aim for.  Iterative victories will move him ever closer to his desired outcome.

 

4. Accountability

This one makes sense, right? What good is having an assess-able goal if you don’t bother to assess it?  I think this has to do with maintaining our intrinsic motivation.  If I have successfully set up my goal with the three characteristics above—if it’s specific, within reach, and easily appraised —then of course I want to know how I’m doing!  This can be done as simply as marking an X on a calendar, as Jerry Seinfeld suggests.  In the photo on this post, you can see my officemates and me doing the same thing.  We can choose accountability only to self, such as on My Fitness Pal, and also to others.  This is why Weight Watchers helps a lot of people—knowing we have to show up and weigh in keeps us honest and on track.  I feel obligated here to point out that accountability does not include shame in any form.  Dictionary.com defines accountable as “subject to the obligation to report, explain, or justify something; responsible; answerable.” Whatever method we choose to report, if it undermines self-esteem or motivation, we need to replace it.

What’s it all for?

Finally, let me address the foundation of the Four A’s: Meaning.  Despite repeated messaging from his doctors, Peter still found it hard to make lasting changes in his habits.  Even the specter of impending disease and disability could not move him to act, despite the rationale that he fully understood in his mind.  But going through the 4 A’s exercise, he realizes that 20 pounds—weight itself—is not the goal.  It’s merely the most tangible representation of his healthier self.  The true “Why” for the weight loss lies far deeper:  To model healthy habits for his girls; to stay active and travel after retirement; to finally take better control of his life.  The closer we can link behavior change to something meaningful and intrinsically motivating, the higher our chances of persistence and success.  For much more riveting descriptions of this concept, I refer you to Start with Why Simon Sinek and Drive by Daniel Pink.

Physicians face multiple demands on our attention. In a fifteen minute clinic visit, how can we more effectively help patients achieve meaningful behavior change?  I am a huge fan of motivational interviewing, and I think the 4 A’s align with this method.  Once a patient reaches the goal-setting stage of change, we can ask the following questions to hone the process and hopefully increase their chances for success:

  1. Can I easily and accurately assess my status in achieving this goal?
  2. Is the goal stated as an action that will move me toward my desired outcome?
  3. How likely will I actually attain the action goal—is it really within reach?
  4. What is the most effective way to keep me accountable for my progress (or lack thereof)?

Thank you for reading to the end, friends, I know this was long. I’ve been thinking through and talking to patients about these ideas for a while now, and applying them to my own health behaviors.  We all struggle with the same challenges.  Our increasingly hectic lifestyles make self-care harder.  As a physician, I will take any opportunity to help refine my patients’ goals and smooth the way to healthier habits.  The ultimate goal is to help them live their best lives, on their own terms.

What Makes You Think You Can Trust Me?

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My friend, we’ll call her Anna, recently had surgery on her pancreas, and she has generously given me permission to share her story. As soon as I heard she was going, I sat up straighter and paid attention. The pancreas is a sensitive organ, and not a common target for surgery, unlike the appendix or gallbladder. “Eat when you can, sleep when you can, and don’t mess with the pancreas,” they told us in med school.

Doctors discovered a growth on Anna’s pancreas in 2014, when abdominal imaging was done for something else. It was an ‘incidentaloma,’ as we commonly call such findings. She had no symptoms, and further tests showed no abnormalities of pancreas function. Everybody agreed to watch it with periodic CT scans. Fast forward one year, she still felt fine, but the mass was still there and appeared to be growing.

Cancer! What if it’s cancer? This ominous question looms over every unknown growth that we find in clinical practice. Pancreatic cancer is particularly scary, because there is no good screening test, and people usually don’t develop symptoms until the disease is incurable. Anna’s doctors started seriously considering surgery. The pancreas sits in the back of the upper abdomen, behind and outside of the abdominal cavity—not easily accessible. It serves both digestive and endocrine functions, and manipulating it can wreak havoc in multiple systems—hence the ‘don’t mess with it’ admonishment.

What to do? The tumor did not have typical cancerous characteristics on the scan; most likely it was benign. But what if it wasn’t? It was growing, albeit slowly. Would this be the rare chance to catch and cure a cancer, and really save a life? And if it wasn’t cancer, what was it? How long could we safely not know? Which would Anna and her doctors regret more: Operating now, risking complications from the procedure, only to find out it was unnecessary? Or continuing to watch, and realizing when finally forced to take it out, that it had already spread? If only there were accurate and reliable predictive tools—crystal balls and such. In their absence, we are left with incomplete information, and our own (in)tolerance for uncertainty and risk. The key for effective decision making lies in all parties’ self-awareness of the latter, and our ability to communicate it. This can be overwhelming, especially when the situation is complex.

Eventually Anna told her surgeon, “I don’t understand everything you’re telling me, but I trust you and I will do what you recommend.” She said he looked up and sat back abruptly, as if shocked by her declaration of trust and willingness to put the decision in his hands.

How would your doctor respond if you said this to him/her? Why would this surgeon be surprised at my friend’s statement? My patients have told me the same thing. What makes you think you can trust me? I think it’s based mainly on two things: Honesty and commitment.

 

I tell the truth.

I learned a long time ago that bullshitting my way through a patient encounter is completely pointless. If I don’t know the answer to a question I need to admit it, period, right there in real time. But just because I don’t know, doesn’t mean I can’t help. I know a lot. I can estimate. I can make a well-educated guess. I can articulate my rationale, explain that while I don’t know for sure, this is what I recommend based on the information in front of me, my past experience, and my personal biases (that last piece is critical). If I’m missing data, I can look it up. How often does an unknown pancreatic mass turn out to be cancer, in cases like this? If it’s very seldom, why do I recommend surgery? Maybe because I watched one too long once and I have always regretted it. This kind of experience will always influence my decision making; I’m kidding myself if I think it doesn’t. My patients have a right to know. It’s not weakness; it’s honesty. When you know my biases, you can decide for yourself how my judgment is influenced, and whether you’re at peace with it. When I own both my expertise and my limits, with humility and not shame, you are far more likely to trust me.

 

I will stand by you, whatever happens.

In order to trust me, you must also feel that I will not abandon you when things go badly. Because if we know each other long enough, something will always go wrong. You will have side effects from drugs. Treatments will not have the desired results. The worst thing I can say to you is, “Well, there’s nothing more I can do for you, goodbye.” There is always something I can do. I can’t cure your disease or bring your loved one back. I can’t make your depression go away. I cannot change your behaviors for you. But I can ask, “How can I help you suffer a little less?” Whether it’s referring you to a specialist or simply sitting with you for a while, my commitment to you, to our relationship, earns me your trust.

 

And, it’s a two-way street.

Here’s an interesting question: How can I trust you, to trust me? What do I need in order to feel comfortable both driving and navigating on this patient-physician road trip? It’s a huge responsibility, after all. I was honest about how well I know the geography and what I think we can expect on the way. I have made a commitment to be your travel partner, whatever the road and weather conditions. I need to know that you have relinquished the wheel and the GPS in an informed way, and that you will stay in the front of the bus to point out hazards and road signs. I need to know that you will not automatically blame me, or leave me, when we run over a nail and get a flat tire, or hit a deer that suddenly lopes across the road. We each need to take responsibility for our own part in getting to our destination.

Anna’s tumor was benign, and now she’s missing two-thirds of her pancreas. I imagine sometimes she wishes she had asked more questions, or decided to wait a little longer. But I think she does not regret her decision to trust the doctors. Her medical team is still intact and monitoring her appropriately. They may take turns again driving and navigating on her journey.

Trust is the cornerstone of any meaningful relationship. The patient-physician relationship is no exception. It takes time and presence to cultivate. These are big investments, and if we are willing to make them, the returns can literally save us.