From Flowers to Dostoyevsky and the Road In-between

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I am sitting in the parking lot, waiting for the local bookstore, The Book Bin, to open. I am here because of a flower. And a pear tree turned maple. And a sense of time and space. And the writer Dostoyevsky.

Sipping my morning coffee, with the Jeep’s soft top down, I feel the heat and humidity of the day gaining momentum. I have ten minutes to kill, but there is no rush. I am in no hurry.

I am not a particular admirer of flowers or plants, nor fond of gardening. You will find no green in my thumb. I struggle to tell the difference between tulips and roses or what qualifies as a annual versus a perennial. Becky is both president and vice-president of landscaping and curb appeal for our home. But every year, after Chicago thaws out from another nasty winter, there is one pink plant I notice from July to the frost.

The routine is one I have done a thousand times. A long day of work followed by a quick drive home. I turn into my driveway, stopping short of the messy garage. I grab my evening Starbucks and step out of the car, making a bee-line for the front door. Just to the left of the brick paver walkway, pink flowers bloom on the tall arching hibiscus plant. Ten year ago, Madison and Maya won an Earth day contest resulting in a hibiscus plant in the front yard and a Pear tree in the back. Now, every time I see the pink flowers, a Pavlovian response follows. See hibiscus; think of Madison. The pink flowers stand out as the summer days get longer. But the reflexive thought is usually fleeting. I have a narrow two-hour window to play catch-up with the family, eat some food, and take care of some odds and ends before getting ready for evening water polo practice.

But this has been a year of change. More weeks off of work than on. Days slower, pressure lower. Options greater. Headspace clearer.

Yesterday, I got out of the car and looked just to the left of the brick paver walkway; pink flowers bloom on the tall arching Hibiscus plant.

I paused.

I deviated from pattern and routine. I literally stepped off the brick pavers and walked through the dirt. I kneeled, and for the first time in ten years, I looked. Not rushed and fatigued, but with the unassuming eyes of a child.

Was it the way the day’s light caught the blooming flower? Or its movement, as it swayed back and forth in the afternoon breeze? I stopped. I looked. Differently. Not with an expectation of confirming what I knew to be true. Not reflexive with a programmed response. But with eyes and mind open in a way they often are not.

Not a simple single color, but pink and dynamic, with pattern and texture. Not just petals, but a flower with a complex architecture that I forgot existed. I am mesmerized. I focus. I take pictures, trying to capture or preserve what my eyes see. There literally is a world of things present that I have not noticed previously, all backlit by light emanating from small slits in the petals left open at the base.

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I have written, in the abstract, about increased time and space since going part-time. But it’s concrete and tangible right here in this flower. My mind is unencumbered by the weight of a twelve-hour work day or a week’s accumulation of fatigue. There is no pressure of a two-hour window closing in on me as I stop to smell the roses; or in this case, the Hibiscus. I walk around to the backyard. A few years ago, we identified the pear tree correctly as a maple. I look up at what was once a six-foot tree which, to my surprise, towers overs me by at least thirty feet. Thick branches, once thin and pliable, have weathered quite a few storms over the years. Despite viewing the tree daily through the kitchen window, I have missed this transformation.

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Patterns and behaviors. Expectations and assumptions. Tools often necessary to get thru challenging days. They consume less energy, tapping less into one’s reserve, to operate more on auto-pilot or cruise control. But that path foreword is limited and constricted. One where the hibiscus remains just a pretty pink flower, and the maple six feet tall.

Time and space. Look left and right. Stop assuming. Be more curious, and have fewer expectations. Break patterns and rethink behaviors.

I didn’t read Crime and Punishment in high school or college. Over the years, when I came across references to the book and its protagonist Raskolnikov, I made mental notes to buy and read the book, but never followed thru. Too little time. Never made it high enough on the to do list. In a few minutes that will change. I am waiting for Book Bin to open and I am going to buy that book.

Time and space. Break Patterns. Rethink behaviors.

Madison comes home soon to visit for a week. He’s about to move into his own apartment in Oregon. Maya’s about to start her senior year, with quite of few colleges on her mind. Becky is gearing up to offer tutoring services in a more formal fashion. We are a family with quite a bit of transformation ahead. But despite the potential and promise of the upcoming year, I am in no hurry to launch myself forward.

Days slower. Headspace clearer.

I drive away from the Book Bin, Crime and Punishment in hand. I am ready to read it. With more time and space. With more curiosity and fewer expectations. And with unassuming eyes and a mind wide open.

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Top 5 Lessons Learned for the New Interns

Welcome new PG-1’s! One day you wake up a medical student. Then by the afternoon you are a MD. A few short days later, you are now in the hospital no longer looking for someone to co-sign your orders in the EMR.

It’s a crazy time, full of excitement as well as an inordinate amount of stress.

My list is not for your first day of the first week. But maybe bookmark it for after you get your sea legs under you. After you know where to park the car and where to get that much needed cup of coffee. This is for after you figured out how to login to the EMR and PACs system and know the pattern (or lack thereof) to your days on your first rotation. Then, come back here and re-read. When you have the bandwidth to actually process. There are many pearls out there for new interns. There are handbooks, pocket guides along with Twitter full of words of wisdom. The five I have written about here I think will serve you well as interns and beyond.

  1. Don’t forget the chief complaint.

My closest calls and near misses over the years have been when I neglected to pay adequate attention to the patient’s chief complaint. They may be in florid heart failure with a pulse ox of 70% and not making any urine. But all they care about is the pain in their calf. While I am placing them on non-invasive positive pressure ventilation, nitro drip and Lasix, two hours later I find them in the OR for compartment syndrome. Their chief complaint may not be at the top of YOUR problem list, but it is at the top of THEIRS. It may not always end up being a life or limb threatening process, but then again, how do you know if you don’t check it out. Always respect the patient’s chief complaint.  If you do not bother to pay attention and address it, what else is your patient telling you that you are not hearing!

2. Ask that question!

If you are uncomfortable asking as an intern, how will you do it when you are an attending? I will let you in on a little secret. We (the attending’s) do not know what’s going on all the time. But I do know where to go to get help. What resources I have in the form of other colleagues, partners, consultants, etc. You are not expected to know everything. Definitely not as an intern. But we doctors can be an interesting bunch. We often feel like imposters, especially early in our training. That we do not belong. Yet we have pride and ego that compete with our feelings of insecurity.  This is an awful construct to have in your head.  Break it. Ask the question. I am willing to bet someone else on rounds has the same one. By asking, you encourage the next person to speak up. By sharing what you do not know, you foster an environment that encourages learning and is better for patient care. More importantly, you will recognize that this doesn’t stop after intern year. Welcome to being a life-long learner

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3. Approach with caution the patient with psychiatric illness.

It’s hard when the patient’s history of mental illness gets put up front during sign-out from the ED or on your chart review. Our biases often kick in whether we intend to or not. Often the patients ability to give a good history and report symptoms accurately gets called into question and their voice gets tuned out in the shadow of their mental illness.  Patients with mental health issues can just as easily develop physical illness. Which often in turn leads to exacerbation or decompensation of their underlying psychiatric diagnosis. Too often we dismiss out of hand their complaints or the “pan positive review of systems”. It is hard when someone’s psychosis or mania or anxiety is raging to discern what is the truth. But be disciplined and approach all patients with same level of concern.  Don’t stop listening and tune the patient out. That abdominal pain, even though it is the 5th time they have been to the ED, can still be an appendicitis. 

4. Don’t fear the family.

I remember dreading walking into rooms with family members. They were more able in body and mind to ask questions and were not so easily dissuaded by my quick in and out of the rooms trying to get thru my morning pre-rounds. I feared them. Not just because of the time they took that I did not have, but also, I felt they would expose me for what I was. An imposter. Unable to answer their questions, I feared more what they made me think and feel about myself.

They fear too. They worry about their loved ones. They are confused, out of place, disoriented and are trying to advocate in the best way they know how. Don’t fear them. Lean into them. Sit down. Answer questions even if it means saying you do not know. Start getting comfortable with diagnostic uncertainty and being able to talk about that with patients and families. Honesty combined with empathy goes a long way towards building trust and confidence.

5.   Recognize wins.

I have written about this before in  another post  10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit  but I think its important enough to include here as well. Learn to retrain your brain. As physicians, we tend to focus and dwell on what went wrong. The challenging patients and families. Frustration over missing labs or delays in imaging. The complications of our interventions. The bad outcomes. The deaths. This is where our brains go when we are most tired and beaten down after an exhausting and non-stop twenty-four hours. But in doing so, we miss out on celebrating our wins. We successfully shepherd so many patients through the treacherous and complex world of medical illness.  Treating a “routine” COPD exacerbation and managing them through their hospital stay to discharge without any drama or significant adverse event is no easy task. But we fail to value our role in this as a win. It is viewed as a baseline expectation. We need to learn that there is nothing given about a patient’s course. If we blame ourselves for the bad, then we must take credit for the good. We focus so much on what goes wrong or in our perceived failures to help or heal our patients we end up ignoring all the positive around us.

Best to all the new interns on the start of a new journey. Exciting times lie just ahead. If you enjoyed this post and want to hear more thoughts on medicine and work-life balance, please sign up to follow this blog!

Balance 2.0?

So, a wannabe author/writer walks in to a writer’s conference…

Sounds like the beginning of a not very funny joke.  But, that was me earlier this month as I attended the Harvard’s Writing, Publishing and Social Media Conference for Healthcare Professionals.  Quite a busy three days. Started at 7AM and  finished after 8PM. A lot to learn and absorb: Improving writing style, understanding the publishing and self-publishing landscape, using social media effectively and with purpose.  During the three days, met some great people that I now know in IRL (in real life).

There were so many take aways but a few things did strike a chord and stand out.

  1. This blog is “static.” Once or twice a month I write something. Probably a little too long and a little too moody (more on that in a minute). Right now, it’s really a one-way communication between myself and you the reader. I would like there to be more engagement and build on what I have started. I would like to provide more content that hopefully YOU the reader find either useful and interesting or entertaining.

 

  1. So I am asking you, the reader, what more you would like to see? How can I  make this more of a two-way conversation? I am looking to post:

 

  • Shorter thoughts and musings on life and themes such as burnout.
  • Write on End of life issues / advance care planning / introduce thought leaders and game changers in this space
  • Timely topics of the day.
  • Interesting book reviews or articles in paper or journals on critical care, end of life care, burnout.
  • Guest bloggers with strong clear voices on interesting and important topics.

 

  1. The last part that threw me for a loop was how morose or weighty my writing must feel to most people. I often dismiss as a joke, when my long-time friends send me a text checking in to make sure I am ok after a typical post. During the conference, it was commented on that IRL I seem different than the “voice” that comes across on the blog (ie: I have a sense of humor, funny/sarcastic and quite social instead of morose, melancholy, moody or morose)

So, to be brief, my BLOG and website is a work in progress (similar to my life in general). But I hope to grow it into something more.  So maybe call it Balance Redux, or Balance 2.0

Come to think of it, lets get this conversation started.  Thoughts on a new name? Anyone….

The pace and path to mindfulness

Fast

I eat. Fast. Often, I consume the food I place on my plate before I even make it to the kitchen table. It’s as if I grew up during times of famine, desperate for each and every morsel. On the rare night my family has dinner together, I am usually finishing just as they are starting, and by doing so, send a not-so-subtle message that I value family time together less than just eating.

I drink. Fast. That first beer stands no chance. After my first “sip”, I look sheepishly at my near empty bottle, while others are still using the bottle opener. The joy and satisfaction of a cold beer on a hot day is made all too brief.

I read. Fast. If I like a book, I will devour it in hours. I will keep turning pages until the first light of day sneaks in under the bedroom blinds, signaling me to stop reading and start getting ready for work. The more gripping the book, the quicker my pace and ironically less time to enjoy my escape.

I see patients. Fast. A necessary skill when the hospital is bursting with influenza, the ICU’s are buzzing with patients on ventilators, and my afternoon office is bustling with overbooked patients. I am relieved when I make it through the day without the weight of unfinished charting and unreturned patient phone calls still to be made. But back home, my escape is not without consequence. I feel a gnawing, growing internal uneasiness at the lack of depth and breadth of my numerous interactions.

Slow

I write. Slowly. Frustratingly so for someone trying to create content and build a platform. But I love to labor over sentence structure and word choice. Although slow, it is not painful. When I am able to put to paper the perfect sentence that captures what I see and feel in my head, it generates a soothing and intoxicating internal harmony.

I listen to music. When I do, time slows, regardless of its fast or slow beat. In my car or at a concert. The chords, notes and riffs are felt more than heard, resonating within. Sometimes I get lost within a space that only exists for a brief moment in time.

I cook. Measured and deliberate. I prefer the feel of certain knives in my hand. Cast iron more than non-stick and the warmth of the oven pre-heating behind me. Whether it’s making homemade pizza dough, baking gluten free muffins or smoking a brisket for the better part of a day, I don’t feel that time has been wasted.

I run. Sometimes for hours. Disconnected and separated from phone and home, my foot cadence becomes my mantra as I let go of the competing forces of work, family and social media. I dive deeper into unresolved thoughts and emotions.

Pace

I first learned about the concept of pacing in high school.  Figuring out a “steady” versus “race” pace was a skill needed to survive swimming thousands of yards day after day. I apply the same concept when training for and competing in Iron-distance triathlons. How fast can I push before burning out too quickly? How do I not leave anything in the tank as I cross the finish line? When I think about the activities and actions that bring me the most meaning and happiness, pace is a dominant factor.

Mindfulness often evokes images of yoga, crystals, incense and oils. But the truth is, when the pace is right, mindfulness comes into play without the need for any new age music in the background. Just as I appreciate the cadence of my breathing on a run or the layering of different tracks on a particular piece of music, mealtime can be transformed from mindless to mindful. Tasting the food and enjoying conversation, while being present and in the moment with my family around the table, becomes so much more than quickly ingesting empty calories.

Applying pacing and mindfulness to an otherwise generic patient encounter opens up opportunities to create a more qualitative interaction. Picking up on verbal and non-verbal cues. Recognizing that what is not being said may be more important than what is. Filling in and clicking on all of the blanks and boxes in the EMR might facilitate an orderly collection of important health data points, but it does not facilitate a natural exchange of information, nor does it create a comfortable space that promotes openness and candor.

We make thousands of conscious decisions every day. What should I eat for breakfast? What shirt will I wear? Do I go for a run or a long bike ride?  What will I write for a new blog post? But we rarely pay explicit attention to the pace of our actions. I have lived most of my adult life moving at a fast clip. Transitioning to part-time gives me the opportunity to slow down and be more cognizant about the pace I choose moving forward. By doing so, I hope to reclaim in my work world the quality that has been absent in some of my recent patient encounters. And when outside the walls of the hospital, I hope to capture more often, that internal harmony or resonance that is waiting for me.  If I can just find the right pace.