We Are Tested


What a shit week.  I wonder, how are you doing, my friends?  Because I look around and it really seems like I’m not the only one feeling it.  A friend’s young, healthy sister-in-law was diagnosed with metastatic lung cancer and possibly also lymphoma.  Another friend’s cousin died from a drug overdose after recently completing rehab and getting back to her young family.  Patients are sick with mysterious and disconcerting illnesses.  Pipe bombs were sent to a slew of Democratic leaders and supporters.  And today a man commits yet another deadly, hate-driven shooting.  Seriously, WTAF?  And I honestly think we have yet to hit rock bottom.  I don’t see any of it turning around anytime soon.

I have barely made it through—so much psychic energy required to simply move from one task to the next, taking care of many (and not so much some others).  This past year, actually, sometimes I’m barely holding it together.  First the knee injury, then taking on a new big role at work.  Then surgery/rehab, and another personal crisis that derailed all of my health habits for spring and summer.  As I go around the country talking about personal resilience and culture of wellness, I wonder, am I being a hypocrite?  Am I really walking my talk?  Because if I’m not, I had better just sit down and shut up.

I wrote to a friend today, “I hope you are able to take care of yourself and recharge.  The energy in the world is so tumultuous and agitated.  It’s no help to blame and lament (well maybe lamenting can be a bit cathartic—for a while).  I guess this is a time to exercise our best skills—sharpen them against the harsh and jagged surfaces of challenge and trial.  I feel like all year my professed self-care practices have been called out and called forth—TESTED.  And I’m still here…  Still doing some good every day (I think), alongside the mistakes, the sub-par moments, the not-my-best words, actions, and thoughts…  But hey, who’s perfect?  Nobody.  And are we all here doing the best we can?  I agree with Brené Brown’s husband Steve, the pediatrician: It helps me live better when I choose to believe that we are—all visible evidence to the contrary.” (Here is another article that describes well the benefits of this mindset.)

CO fall 2018

Similar to last week, as I consider this idea, I am met with readings and conversations that deepen the exploration.  Friend and author Donna Cameron published an op-ed today in which she, in her typically kind and gentle style, encourages us all to be our best and see the best in others—on November 7, a day full of potential for vehement loathing and gloating celebration.  In her wisdom, Donna urges us to think ahead and decide in advance how we will choose to think, speak, and act.  How can we be our best on that day, to ourselves and to one another, no matter what the circumstances?

Recently I have had conversations with trusted friends, my coach, and my therapist, focused on my own most cavernous arenas of personal self-loathing and shame.  How lucky that I have such generous, loving, wise, candid, and brave people holding me up.  With their help, I can move past shame, take a step back, and recognize that I simply have some dysfunctional patterns, just like everybody else.  I slide into these deep grooves when I’m stressed, exhausted, and distracted—they are the default. They are part of me, and also subject to change—to intentional modification, gradual evolution.  These days I meditate often on the distinction between perfection and healthy striving, and I’m also reminded daily of the benefits of cultivating a growth mindset.  These days, instead of berating myself for falling into the same deep hole in my sidewalk, I can hold it more lightly, laugh, and exclaim, “How Fascinating!” climb out (often with a little help from my friends), and walk—ever onward.


Today as I walked outside, slowly (I’m so tired), I noticed the leaves again.  I think autumn is my favorite season.  It reminds me of the wholeness and beauty of transitions.  They are inevitable.  They are temporary (or constant?).  They are unpredictable, at times prolonged, at other times sudden and acute.  They can feel at once painful, joyous, terrifying, shocking, enlightening, overwhelming, confusing, awe-inspiring (or simply inspiring).  It occurs to me that the best way through them involves practicing some combination of mindfulness, self-compassion, empathy, generosity, deep breathing, sleep, connection, self-awareness, magnanimity, and of course love.  The only way out is through, and if we do it well, we can grow a little at a time in the process.


Who knows what shit will be flung our way and hit the fan next week?  How will we cope?  I know I will be leaning on my tribe and looking to make our ties ever stronger and thicker.  Thank you for being here to share the journey.

Holding the Space for Shadow Behind the Light


Have you ever been in an argument and suddenly realized the perfectly mean thing to say, that ultimate verbal weapon that would render your opponent categorically mute and ambush them into abject submission?  It’s an exhilaratingly powerful feeling, isn’t it?  What did you do?  Did you bite your tongue and take the high(er) road?  Did you blunt the skewer and lob something passive-aggressive instead?  Or did you let loose that ax with the full force of rage behind it, just to see what would happen?


I had another convergence experience last week, in a series of articles on my Facebook newsfeed.  It started when I saw this piece on reconciling the parts of ourselves which we subconsciously hate, in order to live more integrated, fulfilling lives, particularly in our relationships with others.  The author discusses Carl Jung’s core ideas, stating, “To heal a split in self, a person needs to work with their shadow and learn uncomfortable truths about themselves in the process. Our inner war is softened when we allow ourselves to be seen. Not just the side of ourselves that matches our intersubjective ideal — that is easy. We show those feathers prominently. No, we need to accept our failures and shortcomings too.”

Yes, I know.  It’s the Sh*tpile all over again.

The Remembrance

I attempted to read a book several years ago, Debbie Ford’s The Dark Side of the Light Chasers.  There is an exercise on page 69 of the 2010 paperback edition in which she lists a set of negative words, such as greedy, phony, cheap, lazy, wimp, fat, passive, coward, etc.  The instructions are as follows:  “Identify the words that have an emotional charge for you.  Say out loud, ‘I am ________.’  If you say it without any emotional charge, then move on to the next word.  Write down the words that you dislike or react to.  If you are not sure…ask yourself how you’d really feel if someone you respected called you this word.  If you’d be angry or upset, write it down.  Also…(think about) words that are not on this list that run your life or cause you pain.”  The list is almost two pages long.

Back around 2011 I did this exercise in earnest.  I wrote down words like controlling, bitchy, rigid, egocentric, better than, arrogant, defensive, judgmental, condescending, oversensitive, and many more.  I’m looking at the list right now, written on a napkin while I sat alone reading at lunch—so long and depressing.  Who knew I hated so many things about myself?  I got through another 40 pages of the book, as evidenced by the bookmark still wedged at the end of the chapter entitled, “Embracing Your Dark Side.”  All I remember is the profound, visceral discomfort I felt after that exercise, the unshakable fear and shame, and how I basically came home that day and picked a fight with my husband that lasted for two weeks.  Not my proudest moments on this journey of self-discovery….  I remember thinking, ‘This is f*ing hard.  How will I ever get on the other side of it all?’

These days, things feel very different.  I’ve done a lot (a lot) more inner work, studied and learned, and enlisted professional help to overcome my aversions to emotional vulnerability.  I’m thinking I could probably pick this book up again, redo the exercise, and have a very different experience.

The Emergence of a Thread

While I pondered this, another article came across my newsfeed, entitled, “What Nice Men Never Tell Nice Women.”  Basically it describes the internal tension between men’s competing impulses: “The nice man is democratic, egalitarian and deeply sympathetic to the feminist agenda – and yet in sexual fantasy, he loves the idea of being tyrannical, bullying and really very rough. He himself can’t understand the disjuncture between competing parts of his nature; he is spooked by the drastic switch in his value-system that occurs the very second after orgasm.”  Wow.

The article concludes with, “It’s clearly very hard for the partners of the nice to take on board the darker sides of their lovers. But if they are robust enough to dare to give them some attention, the result can be an extraordinary flowering of the relationship beyond anything yet experienced. However close we may be to someone because they have been nice to us, it’s as nothing next to the closeness we’ll achieve if we allow them to show us, without shaming or humiliating them, what really isn’t quite so nice about them.

“Out there, in the politer corners of society, nice guys are – without saying a thing, that’s not their style – waiting for nice women to start to gently take the weighty burden of their ‘badness’ off them. And, of course, vice versa too, for no gender has any monopoly on the sense of being bad.”  This last sentence gave me pause and hope.  It turned the tables and made it okay for women to also have a dark side, for us to also struggle with our ‘niceness.’

One of my friends commented, questioning, “So all men are either openly hostile and misogynistic, or are burying their dark feelings?”  I almost reflexively I replied, “I took the article as saying we all bury our dark feelings somewhat, and we can live fuller, healthier lives if we both acknowledge them and manage them effectively.”  Again, I found myself returning to this core idea of grappling with our inner demons.  By now I started to wonder about cosmic timing.  What has the re-emergence to teach me now?  We all have some base impulses, parts of ourselves that we would sooner deny than acknowledge, let alone show to the world.  I wrote about this, rather spontaneously and unexpectedly, at the beginning of the Blogging A to Z Challenge.  Little did I know then that this would become a recurring theme this summer.  It’s as if the universe urges me onward, perhaps sensing that my motivation to dig in my shitpile wanes, when I ought to be digging deeper, integrating more?  Isn’t this what I’m always preaching, to Own Your Shit?  Okay then, I thought, I will stay on the path.

The Dark Side of the Dark Side

The next article to converge on this shadow-themed week came in the form of tweets by a reporter from a Trump rally on August 18th.  People were saying Hillary Clinton should be executed, calling her a ‘f*ing witch,’ calling President Obama a ‘goddamn Muslim terrorist,’ saying ‘reporters need lobotomies, and maybe that’s what Trump will do after elected,’ wanting to ‘hurt the press,’ mentioning ‘a civil war if Trump loses,’ and it goes on.  It occurred to me that these are examples of us not managing our dark sides very well.  The article on Carl Jung and Debbie Ford’s book both embrace the idea of uncovering our less generous traits with compassion, and integrating them for a healthier whole.  These people’s behavior, by contrast, demonstrates the profound risks of allowing those darker impulses to overtake our consciousness, words, and actions.  The container of repression has its limits.  When someone outside applies incendiary words and rhetoric, the fire drives internal pressures beyond the container’s capacity.  If that person then provides a release valve in the form of a similarly aggravated group, well, violence and mayhem are born.

In my previous posts I have reminded myself to remember to look beyond the mob mentality, and listen for the individuals’ personal experiences.  I have to continuously remind myself that we must have more in common than not.  We are all human, after all, and we love our country.  So what could drive people to abandon all social norms of restraint, and unleash such profound loathing into the world?

I came across the final piece in the convergence on Sunday, which offers some insight.  Veteran journalist Joel Stein wrote this blog post exploring the nature of internet trolls.  In it he describes how despite the profoundly abhorrent things these people may write to their online prey, they are not the dregs of society that we may imagine.  He quotes a social media exec: “’The idea of the basement dweller drinking Mountain Dew and eating Doritos isn’t accurate,’ she says. ‘They (could) be a doctor, a lawyer, an inspirational speaker, a kindergarten teacher.  It’s more complex than just being good or bad… It’s not all men either; women do take part in it.’  There’s no real life indicator,” he writes.

Stein describes his experience confronting his own troll of two years, a 26 year-old, small-framed, female freelance writer who on multiple occasions tweeted that she wanted to “kick (his) ass.”  He invited her over Twitter to meet for lunch in order to confront her, and she cheerfully agreed over email.  Excuse me??  During the meal she admitted that she was just lashing out at what she perceived as his ‘smarminess,’ and told him outright, “’It’s clear I’m just projecting. The things I hate about you are the things I hate about myself.’”  And though she had been trolled worse than he, she experienced no sympathy that prevented her from doing it to him.  She expressed incredulity when he asked why she never carried out her threats to beat him up, even when she had the chance.  “’Why would I do that?’ she said. ‘The Internet is the realm of the coward. These are people who are all sound and no fury.’”

So more and more, in both large, impersonal groups and online, our dark sides are given free reign with few, if any, meaningful consequences.  Under cover of the mob and anonymity of the internet, we can freely relieve our repression.  But it comes without any insight, and there is no lasting benefit, for ourselves or those around us.  There is only offloading, a temporary pressure release, only to continue re-accumulating, with unpredictable and potentially very destructive outcomes.

This is not, I think, the manner in which Carl Jung envisioned us coming to grips with our shadow selves.  This is not integration.  Rather it is advanced separation— perpetual splitting of self from self and from others.

The Lesson

So what have I learned?  We all harbor coarse, corrupt, even barbaric tendencies.  We are descendants of cavemen, after all, and still hardwired as such in our limbic brains.  Still, most of us exercise discretion and civility in everyday life, and find ways to get along in society—we exert neocortical controls.  Every once in a while, though, something gets the best of us, catches us off guard, and the ugly slips out.  Sometimes it’s pretty scary ugly.

Once again, I conclude that shaming ourselves or one another for the repugnance is the opposite of helpful.  Just like the offloading behavior that incites our disapproval, automatic ad hominem negativity toward perpetrators of such words or acts only serves to further alienate them, adds fuel to the fomenting rage fires.  When we berate ourselves for our shortcomings, we make ourselves smaller and less resilient–more likely to react with rage rather than respond with gentleness.

In the end I think it’s about judgment.  We can and should judge which attitudes, policies, and behaviors we deem right and good.  At the same time we should exercise caution and extreme patience when we find ourselves judging ourselves and others on worthiness.  The default assumption must be that we are all worthy, that we all deserve a voice, no matter how vulgar and objectionable our words.  We must apply boundaries, and we should expect mutual respect and tolerance; we can find ways to deal with disrespect and intolerance that do not invalidate one another’s innate humanity.

As we each pursue our own inner work, dig in our respective shitpiles, we contribute to the life gardens of those around us, and lead by example.  It can be back- and sometimes spirit-breaking work.  But we must continue.  There is too much at stake for us to take the path of least resistance, the path of separation and alienation.  Let us stay on the more demanding and more rewarding path together, friends–the path of connection.  Let us hold one another up through the shadows, and seek always the light within each and all of us.

Holding the Space for Connection Through the Hard Conversations, Part II


Today I watched this video of Trump supporters at his rallies.  Their words, actions, and expressions represent the basest human emotions.  I posted the video to my Facebook page, commenting:

(Donald Trump incites rage and hate) in his followers. He stokes the worst in people. He provokes the emotional states that preclude rational thought and reasonable behavior–he is the king of emotional hijacking. Nobody ever makes a good decision while emotionally hijacked; that is when relationships and connection are destroyed, often violently and permanently.

And here’s another irony:  We non-supporters are similarly hijacked by his belligerence.  He and his supporters incite us to rail against them all, collectively and wholly as individuals, as racists, bigots, idiots, haters, etc.  Name-calling is the easiest and most convenient way to separate ourselves from what we disdain, what we fear, and what’s too uncomfortable to tolerate.  But how does this help anything?

On my last blog post I wrote:

I intend to avoid:

-Speaking and writing in sweeping generalizations

-Following snap judgments about groups, or individuals based on their group membership

-Labeling and shaming people or groups as ‘racist,’ ’ignorant,’ ‘stupid,’ ‘lazy,’ etc.

Today I wrote about Trump’s supporters:

I’m trying not to label and pigeon-hole these people, trying not to judge them and discard them, just by what I see here.  That only advances the exact mentality I seek to reverse: more separation, more hatred, more “you are less than me, you don’t matter.”

I guess I have to keep reminding myself.

I can hardly imagine what it would be like to sit down, one-on-one, with someone who sincerely supports a Donald Trump presidency, and have a conversation about it.  But I can easily imagine talking to a Trump supporter about the trials and joys of parenting, the breakneck evolution of technology, and a mutual love of Marvel movies.  Who knows, maybe I already do.

I think most of my friends know my political persuasion.  Most of them also share it.  But probably more than I realize don’t share it, and we avoid talking about it.  Why?  Because it’s uncomfortable.  We don’t trust ourselves to avoid the emotional hijacking.  We’re afraid we’ll say something we’ll regret and damage the relationship.  Or (and), we see the only objective of such conversations as trying to change the other person’s mind, or having our mind changed, which feels at the same time futile and scary.  So our avoidance of the hard, uncomfortable conversations is an attempt to maintain connection (with ourselves as well as one another).  We intrinsically understand that our relationships are important.  So we limit our conversations to topics on which we agree.

At this time in our human evolution, however, we are called to do more.  It’s too easy to live in the echo chambers of like-minded friends and media sites.  It’s too easy to filter our perceptions through repetition and reinforcement, to think that our point of view is the only one, or worse, the only right one.  It’s too easy to label others as wholly racist, sexist, bigoted, idiotic, communist, misogynist, mindless, right-wing, extremist, or evil, based on impulsive interactions in comment sections on a blog or Facebook post.  It is simply too easy to fall victim to premature judgment and conviction based on skewed and incomplete evidence.  We are called to so much more.  We are called to the hard conversations, the interactions that require effort and persistence.  Why?  Because the rewards of this work are understanding, compassion, empathy, connection, and love.

My friend wrote to me, “We have to do this work for your beautiful children.”  Yes, my dear friend, for all of our beautiful, innocent children.  Let us model for them what it means to Hold the Space for Connection, even, and especially, when it’s hard.  This is the work we are called to do.

#AtoZChallenge: Xerophyte People

Webster’s Ninth New Collegiate Dictionary

Xerophyte: a plant structurally adapted for life and growth with a limited water supply esp. by means of mechanisms that limit transpiration or that provide for the storage of water.

AC cactus 2016

Photo courtesy of Cyndie Abbott, Green Valley, Arizona, 2016


Water is essential for growth and survival—of plants and animals alike. So how is it that some plants can not only survive, but thrive and even reproduce, with so little water?  On top of that, they also provide beauty, habitation, and even sustenance for others.  Their short-lived flowers splash color onto monochromatic landscapes.  Regional animals are adapted to live nestled among some xerophytes’ barbs.  Survival programs tell us to seek these plants as a source of essential hydration when stranded in the dessert.

Humans share many of these tough flora’s adaptive qualities. We evolved as omnivores, able to eat most things that grow in nature.  Our big forebrains allowed us to cultivate plants to eat.  We learned to capture, then herd, animals for our own use.  We have come so far as to alter and control our environments, in order to live in places where nature may never have intended.

But the more interesting parallel between xerophyte plants and Xerophyte People is resilience.  If we consider metaphorical water for human life, many things come to mind: joy, security, connection, purpose, meaning, love.  Think of all the people who live with little or none of these things.  Think of those who once had these things, and then had them forcibly taken away, often indefinitely—by war, abuse, illness, death.  In medicine, we witness this kind of suffering regularly.  Our hearts break alongside those of our patients and their families.  But it’s not always forever.  In primary care, where I have the privilege of knowing patients over long periods, I have also celebrated remarkable reversals.  New relationships, revelations, births, treatment innovations—you never know what will happen to turn the tide.

So what keeps us hanging on? Like plants, maybe we figure out ways to prevent further loss—limit transpiration.  Thick skin and prickly spines keep us protected.  Only the very persistent or the specially equipped can penetrate our defenses.  But more important, we have adapted to store what we need.  Even if we cannot readily identify or articulate it, something keeps us going.  Maybe it’s hope, remembrance, or some core value or aspiration we have yet to realize—some inner pilot light that never goes out.  Some might call it the human spirit.  Whatever it is, I stand in reverence of its mystery, its utterly saving presence.

To all the Xerophyte People in our world, I say as Glennon Doyle Melton does:  Carry On, Warriors.


Tent Rocks National Monument, New Mexico, June 2015

#AtoZChallenge: Of Trials and Tribes


Since my last post, I’m thinking more about this Tend and Befriend response to stress–to Trials. When I first mentioned it in this post, I did not really understand it, though I thought I did.  I thought it was about empathy, responding to others’ stress.  Later I started calling it the ‘mama bear’ response, but this is not exactly right, either.   It is attributed to a maternal aspect of human nature, but the bear metaphor conveys too much of the ‘fight’ reflex.

As I reread this summary article, I modified my frame to the ‘mama anything’ response.  The author describes work by Michael Meaney at McGill university, that shows the ‘tend’ aspect:

“He and his colleagues remove rat pups from their nest for brief periods–a stressful situation for pups and mothers–and then return them to the nest and watch what happens. The mothers immediately move to nurture and soothe their pups by licking, grooming and nursing them. This kind of tending response stimulates the growth of the pups’ stress-regulatory system.”

Further in the article, the ‘befriend’ aspect is explained:

“Taylor and her colleagues detail evidence from rodent studies and studies in humans that when they are stressed, females prefer being with others, especially other females, while males don’t. Indeed, in humans, women are much more likely than men to seek out and use social support in all types of stressful situations, including over health-related concerns, relationship problems and work-related conflicts.”

YES! It reminds me of a post I wrote last November about Teams.  Now I’m thinking about prides of lionesses, herds of elephants, and Tribes of people.  Throughout my life, I have had Throngs (okay maybe not, but it’s a great T word!) of people to reach out to in times of need.  Off the top of my head, here are some tribes I belong to:



Mama Docs

Mama Docs of Children With Anaphylactic Food Allergies

My Cheng Cousins

My Hwang Cousins

American Born Chinese (ABCs, the so-called second generation)

AHS Warriors

Patient care Teams (including medical assistants, nurses, receptionists, ultrasound technicians, nutritionists, exercise physiologists, and other physicians)

Northwestern University

The University of Chicago

Conscious Life Journeyers

The Counsel of Wisdom and Caring, convened on my 41st birthday


More from the article, research by Nancy Collins, PhD:

“…tend-and-befriend may be just as adaptive for men as for women in certain contexts, says Collins, whose research finds no gender differences when examining how often husbands and wives seek support from their most intimate companions–for example, each other.”

So really, as the article concludes, Fight or Flight(, Challenge,) and Tend & Befriend are just a spectrum of human stress responses.  Not mama bear, not just mamas, not even just parents, but all of us.  Tend and befriend simply describes and exemplifies the basic human need to belong—we all need our Tribes.

#AtoZChallenge: Stress Assessments in a 15 Minute Clinic Visit


In my practice, I focus a lot on stress management. Over the years I have developed a series of questions that facilitate an efficient and productive assessment of stress and its impact on health.  I share this approach here.


Meaning to Stress Ratio

  1. On a scale of 0 to 10, 10 being very high, how high do you rate the overall stress of your work?
  2. What are the sources of stress?
  3. On the same scale, 0 to 10, how high do you rate the overall meaning of your work to you? I mean personally, subjectively, regardless of how you think the world perceives your work, how much fulfillment to you yourself get from your work?
  4. What are the sources of meaning?

Examples of stress sources would be volume, hours, intensity, risk, pressure to perform, and toxic relationships. Examples of meaning sources might include contribution to society, providing for the family, mentoring, supportive relationships, creativity, and intellectual stimulation.

I started asking these questions to patients about seven years ago. I remember the first time I thought to use the trusty 0 to 10 scale to assess stress.  It made the conversation instantly faster and more focused.  Most people answer the first two questions easily, especially if stress is high.  A fair few, however, find the second two much harder.  They often get pensive for a moment.  This is when I know I might be cracking open an important door in a person’s consciousness—a door that, I believe, leads to important discoveries of self and overall health.

Everybody wants high meaning, low stress. But before we idealize ‘low stress,’ let us remember that all stress is not bad, and some stress is required for motivation, challenge, and productivity.

I soon realized, both for my patients and myself, that both the absolute values of stress and meaning, as well as their ratio, play significant roles in health. Let’s take a look:

Low stress/low meaning : Boredom; disengagement.

High stress/low meaning: A different form of disengagement:  Burnout.

Low stress/high meaning: Restlessness: Lack of challenge, looking for something useful to do in service of a cause.

High stress/high meaning: This one is significant.  In my interviews, the people who are happiest in their jobs report this combination.  The key is that meaning must outrank stress—the meaning:stress ratio must be one or greater—and meaning itself must meet or exceed 6/10.  We can tolerate high levels of stress, even for prolonged periods, if we perceive intrinsic value in what we’re doing.  It moves the peak of the stress/performance curve to the right.  In other words, the stress has to be worth it.


The Three Awareness Questions

  1. When you are stressed or overwhelmed, where do you feel it in your body? For example, some people get headaches; others feel fatigued. Others get constipated or short of breath/palpitative. Still others notice mood swings and angry outbursts. While we all likely manifest each of these some of the time, most of us have a telltale sign or two that are specific to us.
  2. What are your existing resilience practices? What do you already do that keeps you from falling off the edge? What keeps you sane on a daily basis? We all have these practices, though it may take some contemplation to identify them. This awareness is important, though, so we may actively monitor. For so many people, exercise is a key stress reliever, and also the first thing cut out of the schedule when life gets busy.
  3. What are your de-escalation practices? When you feel yourself slipping off the cliff (the headache returns, your bowels grind to a halt), what do you do that brings you back from the edge? Examples here might be physical (running, boxing, or otherwise tantruming), verbal (journaling), or other.

When people make the connection between physical symptoms and subconscious stress, they can let go the fear and dread that often accompanies these chronic and often bothersome sensations. They can use them as smoke alarms—signals to take a step back, look around, and see what is out of balance, smoldering, or actually on fire.

Threat-Challenge-T&B Pie Graph

I previously referenced three major responses to stress here.  In summary:

  1. Threat stress: This is what we generally mean when we say ‘stress.’ It’s the fight, flight, or freeze response, when we sense a treat to survival, or we appraise that we lack the resources to cope with our circumstances. It’s mediated by cortisol.
  2. Challenge stress: We face a challenge that we feel at least somewhat qualified to tackle but it will be hard, test our limits. If we’re lucky, it’s something we care deeply about and we rise to the occasion—I’m thinking this could lead to a state of flow. This stress results in increases in DHEA and testosterone.
  3. Tend and befriend stress: This is the Mama Bear response. Under stress, we reach out and protect those around us.  We circle the wagons, bring in the kids, make sure everybody’s okay.  Oxytocin rises here.

If you were to draw a pie graph representing the proportions of these three stress responses in your work, home, or life in general, what would it look like? All three responses are natural, functional, and serve a purpose.  But when threat stress, in particular, becomes chronic and unrelenting, health suffers—we suffer.  Fortunately, there are strategies to convert threat stress to challenge stress.  Here are some resources for that, if you’re interested:




This is now the framework with which I interview all patients about ‘stress’ and its impact on their health. It’s my favorite part of the patient encounter.  This is when I really get to know a person, and learn, from every encounter, how people experience life.  I’ve said it before and I’ll say it again: It’s a tremendous privilege to be allowed into people’s lives so intimately.  My job is to help people live their best lives.  In the hectic culture of the twenty-first century, we cannot underestimate the importance of stress management in that endeavor.

#AtoZChallenge: More Fun, Less Frazzle

“Rule #6: Don’t take yourself so Goddamn seriously.” From The Art of Possibility, by Rosamund Stone Zander and Benjamin Zander.

This can be a hard lesson for physicians. We do such serious work, after all. There is always another patient to see, another result to review, another call to answer—now! But I have to pee, when can I pee?

In my first year of practice, I remember a particularly hard day. I was running late (I’m still always running late) and the patients that day were all complicated. No simple UTIs or colds to give me some air. I huffed and grunted my way through the visits, occasionally buzzing by Rose, my medical assistant, to answer messages in between. My bladder felt like it might actually explode, but I could not stop to go to the bathroom—there was no time! I was so afraid to fall even more behind, to fail in some way. Eventually, Rose posted a sign above my workstation: “TAKE A DEEP BREATH.” It was an instant reality check:  I couldn’t go on like this, I’d burn out before my career even started! Immediately I realized how unnecessary, and downright silly, was all the rushing and grimacing—and I laughed out loud. Since then I have never again reached that depth of anxiety and sullenness in a workday. I am forever grateful to Rose for her sign, her loving reminder to slow down and take perspective. God bless her.

If we’re not careful, we physicians could all easily drown in the drama and strain, over and again, every day. And is that really what our patients need from us—to be Frazzled balls of tension and urgency, bouncing haplessly from one task or person to another, barely holding it together (and in)? Is that what we want for our colleagues and staff, to have to put up with our irritable and pressing demands?

It doesn’t have to be that way. In my third year of medical school, on my inpatient internal medicine rotation, Chip Dye was my senior resident. The service was busy; we always had a full census of sick patients. But I never felt harried or anxious because Chip set the tone for the team. Always smiling, always willing to answer any question, and finding any opportunity to laugh, he made it safe to learn. He exuded confidence without arrogance, calm without sloth. After rounds he led the team to attend morning report (daily educational conference and community gathering).  He always made sure we ate.  And there was always time to pee.

It’s not that he underestimated or ignored the work that awaited us. He just knew that we would accomplish it all better in a lighter, happier state of mind. When it came time to buckle down and divide tasks, Chip prioritized them with realistic expectations and we all got to work. No muss, no fuss, no stress. It would all get done because we laid out our plans in advance.  We self-respectfully reserved time and space for meeting basic bodily and communal needs. Thanks to Chip for leading by example.


From Facebook, I can’t remember where or when!

We can always have some Fun at work, no matter how hard the day gets. Whether it’s telling a silly joke, watching a ridiculous viral baby video, or posting a fun meme on the workroom bulletin board, lightening the mood helps everybody get through a little easier. Laughing relaxes us. Stephen Colbert is quoted as saying, “Do you know what I like about comedy? You can’t laugh and be afraid at the same time—of anything. If you’re laughing, I defy you to be afraid.” And if we can overcome our fears of not getting it all done, of not being enough, we will all be better off—physicians and patients alike.


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