Stability is Strength

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The holidays are coming.  People will be bustling up and down Michigan Avenue with large shopping bags and puffy coats, fuzzy hats and determined gait.  If someone knocked into you on the sidewalk, would you be stable enough to hold your space and not get pushed over?

I asked this to a friend today, a woman about my height and twenty pounds lighter, ‘bird-boned’ by her own description.  I swear, she looks like a feather to me.  We were talking about our habits, what seems to be changing as we approach menopause, and how we envision our best selves in old age.  I thought about the elder women in my family, who are all healthy in general, but not necessarily fit.  What if someone knocked into them this holiday season, would I be dealing with a hip fracture over Christmas?  The mortality rate for people over 65 in the year after a hip fracture is somewhere on the order of 25%.  My friend and I definitely do not envision this for ourselves.

So what needs to happen in order for me to stand my ground in the face of some external force?  I need a stable foundation, my feet in firm contact with the ground.  I need a low, massive center of gravity.  I need fast reflexes to contract and relax opposing muscles groups to bear the sudden and unexpected load.  I cannot be rigid and brittle; rather I must exert flexibility, to absorb enough force to move with it and away from it on my own terms.  I need to stand tall and face the force head on, with openness and grace, firmness and self-assurance, ready to assess instantly whether it was inadvertent or intentional, benign or malicious.  And then I need clear-minded judgment to determine how to respond to either condition.

This may come naturally and easily in our 20s.  Today, bum knee notwithstanding, I feel confident that I could meet such a force with appropriate strength and stability.  My friend and I agreed today on a shared vision: STRONG OLD LADIES.  We understand that this will not just happen because we will it; we need to fuel and train, rest and recover, and cultivate our mind-body connections, as well as our connections with others.  Small habits, sustained over time, positive or negative, will yield predictable results.  So the time is now to pay attention and establish some excellent patterns.

It occurs to me that this idea of stability and strength relates our physical to our mental and emotional well-being.  While Amy Cuddy’s research has recently been called into question, I still adhere to the idea that power posing and physical posture can enhance or diminish confidence and self-efficacy. Wide stance, low center of gravity, elongated spine, and open arms:  Stand strong, feel strong, think strong, speak and act strong.  I have practiced power posing before presentations since 2015 and I believe I am better for it.  And if it’s a placebo, I’ll take it—the benefits so far have outweighed the risks and costs.

Lastly, I think we can also apply this stability and strength awareness to our inner lives.  Here I refer to our integrity.  Our world changes ever faster, technology offering capabilities we had not dreamed even a decade ago.  It seems every interaction these days is shorter, more ‘efficient,’ less personal.  That is the default goal—low cost, high speed above all else.  Change is often good.  But we must also exercise judgment, and practice taking the long view, casting light from our core values onto a cautiously optimistic future, attending to and addressing the shadows.  We should gut-check, with ourselves and one another.  What are we really getting here?  How will we use it mindfully? How can it serve us, rather than us serving it?  When we are stable and strong in our shared humanity and collective goodwill, we arrive at the best answers to these questions.  Then we can all be stable and flexible, and stronger as we age together.

 

Hopey, Changey Hero Making

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NaBloPoMo 2017: Field Notes from a Life in Medicine, Day 8

Funny how I just wrote last night about connecting new dots to old dots.  It just happened again tonight!  A couple of weeks ago I responded to an online ad for an IVY Ideas Night with David Litt, author of Thanks Obama: My Hopey, Changey White House Years, entitled, “How to Inspire, Persuade, and Entertain.”  Litt was a senior speechwriter for President Obama, so I thought I could learn new tips for presentations, and feel a little closer to the president whom I miss so much.

I’ve done public speaking since eighth grade, when our speech teacher first taught us abdominal breathing and I discovered the thrill of holding the attention of a room full of people with only my words.  I work at an academic medical center and I hold zero publications, but my CV documents over 10 years of professional presentations to various audiences.  I thought I was pretty good at this speaking thing.

Three years ago I came across this TED talk by Nancy Duarte, whose ‘secret structure’ of great presentations I have used since I subsequently read her book, Resonate.  Essentially, she recommends that we invite audiences on adventure stories, create active tension between what is and what could be, and most importantly, make the audience the hero.  I have done this better and worse since then, but I always recognize the framework when I see it.  Those familiar with this blog know that I am also a fan of Simon Sinek, whose central message is that we perform at our best when we are crystal clear about our Why.  “People don’t buy what you do, they buy Why you do it,” he says.  Barack Obama employs both authors’ principles with eloquence and finesse, which I noticed reading We Are The Change We Seek, a collection of his speeches as president.  The best speeches delivered in this construction create audiences who are inspired, motivated, and empowered to hail a meaningful call to action.

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That’s basically what David Litt conveyed tonight.  When asked what advice he was given that served him best, he said, “Imagine someone in your audience will tell their friend tomorrow about your talk.  What is the one thing you want them to say about it?”  What is the Why of your talk?  Even though he no longer writes speeches for the most powerful person in the world, he expressed a desire to continue inspiring, empowering, and promoting personal agency in all whom his work touches. Make each and every audience member their own hero.

It turns out, however, that this approach applies to much more than public speaking.  On my 50 hour, 500 mile, aspen-pursuing weekend in Colorado last month, I described to my dear friend my favorite moments at work.  At the end of a patient’s day-long physical, after I have spent 90 minutes listening to their stories of weight gain and loss, work transitions and complex family dynamics, and reviewing their biometrics and blood test results, I meet with them for an additional 30 minutes to debrief.  This is when I present an integrated action plan compiled by the nutritionist, exercise physiologist, and myself.  It is a bulleted summary of our conversations throughout the day, centered on the patient’s core values and self-determined short and long term health goals, and crafted with their full participation.  I get to reflect back to my patients all that I see them doing well, and shine light on areas for potential improvement.  It’s an opportunity to explore the possible—to Aim High, Aim Higher, as the United States Air Force exhorts.  I often present the plan with phrases like, “Strong work!” “You’ got this,” and “Can’t wait to see what the coming year brings!”  My friend turned to me as we wound through autumn gold in the Rocky Mountains, a bit tearfully, and said, “You make them the hero of their own story.”  Yeah, I do, I thought, and I got a little teary, too.

Words are powerful.  They are our primary tool for relating to each other, for making another person feel seen, heard, understood, accepted, and loved.  You don’t have to be a public speaker or a presidential speechwriter to make a positive difference with your words.  At work, in your family, with your friends, with people on the street and in the elevator—what is the one thing you want someone to remember from their encounter with you?

What If I Slip?

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NaBloPoMo 2017: Field Notes From a Life in Medicine

40 hours out from my non-traumatic, sports-induced knee collapse, I’m off crutches, woo-hoooooo!  The knee is still swollen and stiff, and people still look twice when they see me limping.  I’m thinking of ordering from Peapod–the thought of walking around the grocery store, which I normally love doing, makes me wince a little.

I’m much more afraid, though, of the back slide that may ensue in these next days and weeks.  I’ve worked so hard the last few years, establishing and entraining an excellent exercise habit, and I was just hitting a period of new growth and ability, so exciting!  I was getting lighter and nimbler on my feet, and now I lurch clumsily, Trandelenburg-like (not really, but kinda).  All year I have felt sluggish and tense if more than two days went by without a work out.  I barely moved yesterday and I loved it, which scares me.

The last few months also saw a shift in my eating, recapturing a sense of control.  I was eating less without hunger or feeling deprived, and though my weight had remained roughly the same, my figure was noticeably streamlining.  I liked looking in the mirror again.  Last night I found myself grazing steadily after dark.  …Stress eating sucks.  I only recognized a few years ago that I do it, and I have since had much more empathy for my patients with similar patterns of food, tobacco, alcohol, and other ‘substance’ use.  I know I should not be shoveling tortilla chips, ice cream, cookies, and candy in my mouth at 10pm.  I know I don’t need the calories, I’m not really hungry, and I will feel guilty on the other side.  And I do it anyway.  It comes in cycles, and I have yet to find a healthier behavioral alternative in those moments (drink a full glass of water, get on the elliptical, drop and 20 push-ups!  Ooo, that last one might work…).

The point is, I really worry how this setback with my knee will derail and reverse all that I have accomplished until now.  (hyperventilation) GAAAAAHH!!

But wait, the injury was less than two days ago…  And I continue to feel better, regaining range of motion and limping slightly less with the help of ibuprofen and RICEing.  What did I write the other night about resting and recovering?  And what I have been preaching to patients about mindfulness, radical acceptance, and doing what you can at the time?  About small change steps sustained over time, and about how worry is counterproductive, because to paraphrase Michael J. Fox, if what you’re worried about actually happens, now you’ve lived it twice!?

Okay, I’ got this.  Plenty of movement I can still do with a bum knee (including maybe push-ups when I feel a late-night ice cream hankering).  I’m still the same motivated workout beast I was 60 hours ago, the same person who just got through a 30 day food challenge with only minor transgressions.  And JEEZ, it’s only been 40 hours.

Well thanks for helping me work through that, my friends.  I’m good now.

The Doctor Becomes the Patient

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Grandma Has Hurt Herself.

Tonight at volleyball, I was given the perfect set, my timing was getting better, I sprang and hit the ball over the net… I think it landed in, but I was distracted by the crunching sensation and noise I felt in my left knee, and then breathtaking pain as I landed the jump.  Immediately I went rolling, writhing on the floor, lamaze breathing long and slow (nice how that comes in handy at times like this).

As I sat sidelined, the medical inventory began:  No torsive forces, just a buckle.  No ankle or hip pain, only knee.  It’s the bad knee, had similar pain landing a little jump a few months ago, though not nearly this bad.  Pain primarily posterior, deep, left of center, worse with knee extension and dorsiflexion.  Anteromedial joint line pain with weight bearing.  Immediate but mild swelling/effusion.  Hmmm, maybe medial meniscus, possibly also PCL strain/tear?  When should I get the MRI?  How long before I can start PT?  Where is that knee sleeve I got before?  600mg ibuprofen STAT.

The young people were so loving, gathered around asking me where it hurt, getting ice, helping me up, grabbing blocks to put my leg up, glancing over empathetically as I RICEd.  I felt cared for and also embarrassed.

Not just embarrassed.  I felt guilty, maybe even ashamed.  What had happened?  I’ve been training, I’m a good jumper, what did I do wrong?  Was it karmic payback?  I left home just as my kid was struggling with some homework—but nothing I thought she couldn’t handle.  Or maybe I had been getting too cocky that I could actually do this at my age?  Just yesterday I posted videos of my most recent progress on the TRX—I was openly bragging–“toot-toot!” I wrote gleefully.  Or it was an error in judgment: I have not slept enough this week, and I knew I was tired before I went tonight.  But I wanted to go meet my new friends, I wanted to play and have fun.

The frustration came all at once, and with considerable force.  Thankfully I had a friend nearby with a consoling ear and some crutches to lend.  All athletes get injured, she said.  I didn’t do anything wrong.  Yes, I’ve been training, and I was also weekend warrioring it all these months.  This has been my problem knee for at least 15 years, maybe it was going to happen anyway.  It’s still interesting to watch, almost from outside myself, the emotional lava lamp of fear, regret, anxiety, dread, catatrophization, and sorrow.

Experience and maturity, however, make me optimistic.  It’s a temporary setback, and I have resources available to me for recovery, growth, and even enhancement.  Now I get to learn how to use crutches, and I can relate much better to my patients with knee injuries.  I also get to test my newly formed theory that though we may slow down in general with age, we need not resign ourselves to inevitable and morose decline.  Patients ask me often, what should they expect to be able to do at this age or that, how can they know their limits?  For a long time I had no good answer.  But as I have regained strength, endurance, stability and mobility these last few years (tonight notwithstanding), I now tell them: It depends on what you want and how much you invest.  My 1977 Oldsmobile will not run like my 2012 Highlander.  But if I really want to drive that thing, I can put in all the special care and maintenance required and make it roadworthy.  It’s the same with our bodies.  They are incredibly resilient and adaptive, and also mortal.  So we must Fuel and Train, then Rest and Recover appropriately.

I guess I pushed past my current limits tonight.  Setback acknowledged.  I don’t regret the last five months–I made new friends and played and had fun!  I anticipate a high-learning road to recovery.  And I think I’ll get back before they forget me.

 

 

Applying the Wisdom of Atticus Finch

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“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.

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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.

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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.

 

Love You Into Being

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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.