Healthy Healers

     “In 1999, after 8 years of curricular research and review, Indiana University School of Medicine restructured its formal curriculum and graduation requirements around 9 competencies deemed essential to excellent medical care:

1.    Effective communication

2.    Basic clinical skills

3.    Using science to guide diagnosis, management, therapeutics, and prevention

4.    Lifelong learning

5.    Self-awareness, self-care, and personal growth

6.    The social and community contexts of health care

7.    Moral reasoning and ethical judgment

8.    Problem solving

9.    Professionalism & role recognition.”

Cottingham AH et al. Enhancing the informal curriculum of a medical school: a case study in organizational culture change. 

J Gen Intern Med 2008; 23(6): 715-22.

Photo: Brigitte Lorenz   http://www.brigittelorenz-photography.com

Reflection

“Knowing others is intelligence; knowing yourself is true wisdom.
Mastering others is strength, mastering yourself is true power.”           Lao-Tzu

“all that we need to know
all the wisdom of the cosmos
we will find in our own heart”          Mother Teresa

     “it is important to consider the deep underlying similarities that unite schools (of wisdom) even across religious and philosophical traditions. An important unifying theme is that developing wisdom requires a radical transformation of lived experience, one that occurs in identifiable stages. ... both Tibetan Buddhism and Sufism require practitioners to overcome preconceived notions and expertise and return to a ‘beginner’s mind’. Only then can people enter on a path that will lead to wisdom, a path that is in many ways self-secret, because only the mind that is prepared can appreciate the teachings that advance one along that path.”

     Ferrari M, Potworowski G, eds. Teaching for Wisdom: Cross-Cultural Perspectives on Fostering Wisdom. Heidelberg: Springer. 2008. 

     Take time - savor these words - chug-a-lugging a bottle of rare vintage wine misses the point. How often in my daily life do I "speed by" only to miss the point?

 

Words by Joseph Campbell, Music by Yo-Yo Ma

Opportunities

"The first half of life

we serve society - engagement.

The second half of life

we turn inward - disengagement."

"Opportunities

to find deeper powers

within ourselves

come when life

seems most challenging."

"We cannot cure the world of sorrows,

but we can choose to live in joy."                         Joseph Campbell

       Osbon DK ed. Reflections on the Art of Living. A Joseph Campbell Companion. HarperCollins, NY, 1991.

Photo: Andre Gallant   http://www.andregallant.com/

Maturation

     Throughout life, we sequentially assume self-concepts that more and more accurately embrace life's complexity, and are better and better able to bring us real peace and joy. There's an intimate relationship between self-concept and worldview - both evolve if we mature normally.

     If we stop playing the piano on starting professional studies, our piano-playing skills progressively diminish 10, 20, 40 years down the road. The same holds for our inner life, if all our time and energy is directed outward to our career. "What you don't use, you lose."

     After devoting essentially everything we have to our career, how could we feel even remotely adequate at any other tasks? Is it surprising that many of us "will never retire"? A colleague's physician father was extremely upset recently because his research grant had not been renewed. He's 90 years old. It requires deep reflection to distinguish love of work from fear of moving on.

     Undergoing life transitions IS stressful, but we have no choice. Avoidance is not a healthy, satisfactory option.


     "To transform a transition from a threat to a learning opportunity, medical education should assist students and doctors in developing the coping skills they need to effectively deal with the challenges presented by new environments.”
       Teunissen PW, Westerman M. Opportunity or threat: the ambiguity of the consequences of transitions in medical education. Med Educ 2011; 45(1): 51-9.

     See: http://mindfulnessforeveryone.blogspot.ca/2013/02/286-human-journey-from-simple-facts-to.html
 

KIROVBILBAO   www.dpreview.com

"Unacceptable" doesn't work

“I have finished my dissection of the wrist and hand.

It is 3:00 pm, and I have to pick up my daughter from school.

I hold her hand tightly as we cross the street.

She notices, but doesn’t say anything.

Her hand is soft and warm despite the January cold.

This is what life feels like, I say to myself.

I have learned something about the human touch.

I will never hold someone’s hand the same old, ignorant way again.”     Rajiv Gupta, 1st year medical student

        Bertman, S. L. "One breath apart. Facing dissection." Baywood Publishing Co, NY, 2009.

     "Shrinking away from death is something unhealthy and abnormal which robs the second half 

of life of its purpose."          Carl Jung

 

     "The conquest of the fear of death is the recovery of life’s joy.”             Joseph Campbell

Photo: Andre Gallant    http://www.andregallant.com/

Balancing Act

     I considered myself at least average in terms of muscular strength for a 63 year old male, having worked out fairly regularly on a variety of exercise machines for many years. I've never been flexible, and aging hasn't helped!
     It's been a real eye-opener (OK - shocking!) starting yoga classes for the first time. It turns out that I have minimal core strength - ALL the ladies in my class (in their 40's-60's), are stronger! Not surprisingly, they're also all more flexible than I am.
     As in everything else, balance is also key to physical fitness. Strong muscles need to be balanced by core strength, flexibility, and aerobic fitness. All my life I've unknowingly, automatically, overcompensated for my weak core strenth and poor flexibility, by distorting my body, instead of directly addressing my deficiencies.
     Isn't that a natural tendency? Aren't we attracted to activities in which we excel, and remain blind to or even actively avoid ones that we most need to balance our abilities and life? Living wisely is truly a balancing act - one which requires psychological flexibility.

  

     Psychological flexibility is defined as “contacting the present moment as a conscious human being, and, based on what that situation affords, acting in accordance with one’s chosen values. … (It) guides people in persisting with or changing their actions, in accordance with the values-based contingencies that they contact, when they are willing to experience the present moment.”

     Bond FW, Hayes SC, Barnes-Holmes D. Psychological Flexibility, ACT, and Organizational Behavior. Journal of Organizational Behavior Management 2006; 26(1-2): 25-54.

     “Psychological flexibility spans a wide range of human abilities to: recognize and adapt to various situational demands; shift mindsets or behavioral repertoires when these strategies compromise personal or social functioning; maintain balance among important life domains; and be aware, open, and committed to behaviors that are congruent with deeply held values.” 
     Kashdan TB, Rottenberg J. Psychological Flexibility as a Fundamental Aspect of Health. Clin Psychol Rev 2010; 30(7): 865-878.  
 

     

Fine Arts Students, Florence, Italy

Resilience

     “Resilience is the ability to adapt to life’s ever-changing landscape and recover quickly from stressors and potential stressors. Agility is the ability to do so quickly and in a variety of situations.”

     Pipe TB et al. Building personal and professional resources of resilience and agility in the healthcare workplace. Stress Health 2012; 28(1): 11-22.

     Besides just living our lives, is there a way to cultivate resilience and agility? Although I've never come close to being a competitive athlete, I've observed and admired how many top athletes are able to take the discipline acquired from the "practice" of their sport, and generalize this into living highly productive, rewarding and balanced lives. 

     Two of my classmates in dentistry were "the" stars on the University of Toronto hockey team, which in turn was the best in the country. Another classmate was a star on the university's swim team. These three cultivated the discipline and concentration to accomplish - well - in several hours less per day (practice & competitions) than the rest of us.

     All of us can be athletes in our own way, regardless of age. 

     No matter how bedraggled I feel at the end of a workday, and just want to get home, eat, and veg out, I get myself to the gym regularly. Once there, I'm quickly wide awake, and the workout goes just fine. I never leave the gym regretting the workout. I'm always refreshed, energized, as if I'd taken a brain shower. Afterwards, I sleep like a log because my body is more tired than my mind.

     For a bit of competition - I'm currently participating in a version of "the biggest looser" among 30 of my colleagues. Being a tad competitive, we've been exercising much more regularly, and eating much more mindfully and moderately. As a result I've lost 6 lbs over the past month - feels great! We plan to maintain these healthy habits - life-long athletes.

     Be well - be an athlete and a healer!

Photo: Zman53   www.dpreview.com

 

Meaning

     "Finding personal meaning in one's work imbues even the most routine of tasks with satisfaction and even joy. Meaning enables us to recognize the authentic value of our work and of our lives. And in times of crisis meaning heals us, not by numbing our pain or distracting us from our problems or comforting us, but by reminding us of who we are and what we stand for. Shared meaning reminds us that we do not stand alone. 

     As physicians, most of us lead far more meaningful lives than we realize. Because we are distracted by time pressure and the countless details of practice, it is possible for us to do profoundly meaningful work without ever experiencing a sense of meaning. The meaning of the work is there, nonetheless. Many of today's medical care organizations offer little support for incorporating the traditional values of our profession into the daily care of patients. However, we cannot wait for others to recognize our needs and to devise programs that will help us reclaim the soul of our work. Because doctoring has never been more difficult, it may be part of our responsibility as professionals to fight for our sense of meaning against fatigue and numbness, overwork and unreasonable expectations - to find ways to strengthen it in ourselves and in each other.”           

     Rufsvold RM, Remen RN. Finding Meaning in Medicine: Reclaiming the Soul of Practice. San Francisco Medicine, May 2002.

http://www.sfms.org/AM/Template.cfm?Section=Home&CONTENTID=1684&TEMPLATE=/CM/ContentDisplay.cfm

Rachel Naomi Remen MD      

Core issue

     It is anything but ‘selfish’ to ask ourself the open question 'Who am I?' - to search out, perhaps rediscover, and nurture our core values. In fact, American educator Parker J. Palmer suggests: “The most practical thing we can achieve in any kind of work is insight into what is happening inside of us as we do it. The more familiar we are with our inner terrain, the more surefooted our (work) – and living – becomes."
 
     "When we are rooted in true self, we can act in ways that are life-giving for us and all whose lives we touch. Whatever we do to care for true self is, in the long run, a gift to the world.”
 
       Palmer PJ. “A hidden wholeness: The journey toward an undivided life.” John Wiley & Sons, San Francisco, 2004.

Photo: wrosenthal   www.dpreview.com

Namaste principle

     "Integrative medicine ... is about recognizing that personal wholeness and physical limitation often coexist (( for patient & healer )) and moving the focus of care beyond the cure of the body to the healing of the whole person. It is about inviting our patients into our examining rooms as whole people and meeting them there as whole people. It is about recognizing that as whole people, we bring a far greater capacity to meet with the challenge of disease than we have been trained to recognize."
     Remen RN. Practicing a medicine of the whole person: an opportunity for healing. Hematol Oncol Clin North Am 2008; 22(4): 767-73.

     The same principle applies when we find ourselves in leadership positions.

     "I have learned that I can engage people more completely when I treat (my crew) as complete people, with a bigger view than my immediate need for their work. ... in the end all leadership is about engagement."

     Stookey CW. Keep Your People in the Boat. Workforce Engagement Lessons from the Sea. Alia Press, Halifax, NS, 2011.

     Our way of being shifts when we recognize that part of us that is fundamentally good, unbroken and wise. Then we can see and respect the same quality in any person before us, even when outwardly they appear very different from us eg very ill or even dying. Meetings become one of profound mutual respect between equals.
     McGill's program for "Whole Person Care": http://www.mcgill.ca/wholepersoncare/

Levels of Effectiveness - Pam Weiss   http://www.appropriateresponse.com/

 

Reclaiming

In a letter to the editor, Smokey Stover MD comments:

      "It is truly ironic that our increased ability to cure has been accompanied by a decreased ability (or is it inclination?) to heal. In the course of my clinical years I had the privilege of being connected to individuals at birth and death... Despite my relative technical impotence - birth happens well most of the time regardless of what you as a physician do, and the deaths were not preventable – these were the times I felt closest to my patients and were the times of the greatest bonding.

      One cannot help but wonder about how the tremendous financial burdens with which our young physicians enter practice and their expectations of an affluent lifestyle impact their ability to assume the role of healer. A generation or two ago, physicians were revered icons in their communities but lived a very modest lifestyle. Today, they are affluent by virtually all community standards, but suffer from the malaise of a loss of identity and prestige. We need to reclaim our own souls, and, in the process, learn to heal again." 

http://www.annfammed.org/content/7/2/170/reply#annalsfm_el_10754?sid=460bdfb6-837b-4c1c-b527-3d427bfb5c4a

Parker J. Palmer: “Leading from Within: Reclaim Selfhood in Professional Life” (skip 8 minute intro):

http://forum-network.org/lecture/leading-within-reclaim-selfhood-professional-life

Photo: RuthC   www.dpreview.com

Mindfulness & Stress management

     “One of the most well-researched stress management programs is mindfulness-based stress reduction (MBSR). MBSR teaches mindfulness, which is the ability to attend to thoughts and emotions as they arise and to be fully conscious of the present-moment experience. Taught to more than 5,000 medical patients since its inception more than 20 years ago, MBSR is typically run as an 8-week course instructing mindfulness through the practice of meditation, body scan (a type of guided awareness), and hatha yoga. One of the strengths of MBSR, in contrast to most stress-reduction programs, is that it offers participants different mindfulness practices from which to choose. Research indicates that participants often find one of the three practices more beneficial or preferred for personal reasons; consequently having options can improve compliance. This may help explain why MBSR has been found to have high compliance rates, even after 3 years.

      MBSR studies with varied populations have found significant decreases in anxiety/depression, mood disturbance, somatic symptoms of stress, and present-moment pain. Other mindfulness-based studies have demonstrated improvements in quality of life, health-related quality of life, general health, sleep quality, and immune function and decreases in psychological distress and physical symptoms and conditions. Findings from a 3-year follow-up evaluation revealed maintenance of reduced levels of anxiety and depression, thus demonstrating the long-term effects of this program.”

      Schure MB, Christopher J, Christopher S. Mind-body medicine and the art of self-care: Teaching mindfulness to counseling students through yoga, meditation, and Qigong. Journal of Counseling & Development 2008; 86(1): 47-56.

Introductory details about mindfulness training from step #1 to ... :

http://mindfulnessforeveryone.blogspot.com/

Jon Kabat-Zinn, founder of MBSR, speaking at Google

 

Perfectly human

     Within the past few days, two of my friends and colleagues shared with me, at some length, their experience with severe depression. They both said they feel vulnerable without their usual bubbly outgoing persona. Yet to me, these conversations felt much more honest, and yes comfortable, than our previous exchanges. Pretense gets in the way of authentic connection.

Clara Hughes interview by George Stroumboulopoulos

http://www.cbc.ca/strombo/videos.html?id=2194093449

     At a recent meeting with a group of physicians, a senior specialist openly shared with us his experience with depression and how this experience had given him an entirely new perspective - a much kinder, more human view and approach to himself and others. Another senior physician spoke about his recent heart surgery, and the profoundly positive impact that has had on his personal and professional life. 

     When we accept our own humanity, then share it with select colleagues and patients, it's a huge gift - it gives all of us permission to be human too.
 
           "There is a crack in everything
           That's how the light gets in."             Leonard Cohen "Anthem"

Leonard Cohen singing "Anthem" live in London 2009

Self-compassion

     "When one experiences compassion, one notices and is moved by the suffering of others, so that the desire to alleviate their suffering arises. Compassion for the failings and misdeeds of others is also met with understanding instead of harsh condemnation that simplistically reifies people as bad, so that unskilled actions and behaviors are seen in the context of shared human fallibility.  

     Self-compassion involves taking a similar stance toward one's own suffering, so that one is kind and understanding toward oneself when failure, inadequacy, or misfortune is experienced. Self-compassionate individuals recognize that pain and imperfection are an inevitable part of the human experience, something that we all go through instead of an isolated occurrence that happens to "me" alone. Having compassion for oneself also involves taking a balanced perspective on negative self-relevant emotions, so that personal pain is neither suppressed and denied nor exaggerated and dramatized. 

     Most people say they are less nurturing toward and more harsh with themselves than they are with other people. Self-compassionate individuals, however, say they are equally kind to themselves and others. Self-compassion can be thought of as a type of openheartedness in which the boundaries between self and other are softened -- all human beings are worthy of compassion, the self included."

     Neff KD. Self-compassion: Moving beyond the pitfalls of a separate self-concept. In: Wayment HA, Bauer JJ. Transcending self-interest: Psychological explorations of the quiet ego. American Psychological Association, Washington, DC. 2008.

Kristin Neff PhD on Self-compassion & Self-esteem

 

DNA, Beliefs and Biology

     Bruce H. Lipton PhD shows how we continuously learn from, and evolve to adapt to our environment, based on its effect on our DNA (epigenetics).

     Our beliefs, and the beliefs of those around us, are also critically important environmental inputs that directly affect our DNA and thus biology. This, at least partially, explains the biological basis of placebo / nocibo effects, and perhaps more importantly, the importance of our overall attitude toward life (worldview).

     Details of Lipton's biological perspective in "The Wisdom of Your Cells": 
         http://www.soundstrue.com/authors/Bruce_H_Lipton/

Brief (7 min) overview:

An ounce of prevention ...

     William Osler's writings "are replete with concern about his own burnout and that of his colleagues. In a talk to medical students in 1899, he said, 
     ‘Engrossed late and soon in professional cares — you may so lay waste that you may find, too late, with hearts given way, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.’ "
     For a long time we've known that we must go beyond dealing with physician impairment, and actively promote well-being. The impaired physician model does not adequately address the issues of stress, burnout, change of jobs, change of specialty, and early retirement.

Ulwelling JJ, Christensen JF. Northwest Center for Physician Well-Being. West J Med 2001; 174(1): 70-3. 

      Too many of us, however, still operate on the cliche "If it ain't broke, don't fix it." Like other changes, we start getting serious about self-care only when "at the stage of readiness." But do we have to wait for a wheel to fall off the cart - after family, colleagues, and perhaps patients had been watching the wheels wobble for years?
     Though new to some of us, can we learn to self-reflect, listen to our bodies, and listen to our families and friends?

 

Core of resilience

     “How strange that the nature of life is change, yet the nature of human beings is to resist change. And how ironic that the difficult times we fear might ruin us are the very ones that can break us open and help us blossom into who we were meant to be.

     Everything can change in a moment; we have little control over the outer weather patterns as we make our way through the landscape of life. But we can become masters of the inner landscape. We can use what happens on the outside to change the way we function on the inside. This is the moral of the great teaching myths. The hero conquers a monster; the heroine completes a quest; the reward at the end was there all along – the true self, the awakened consciousness. Joseph Campbell said, ‘What all myths have to deal with is transformation of consciousness. You have been thinking one way, you now have to think a different way. Consciousness is transformed either by the trials themselves or by illuminating revelations. Trials and revelations are what it’s all about.’

      When we have been through a trial and survived it – or better still, transformed its terrors into revelations – then we begin to approach other adversities with a different attitude. Change and loss may still knock us off the horse, but soon we are back in the saddle, stronger and wiser than ever. As life progresses, and we continue to transform and refine our consciousness, we gain more insight and humility, greater strength of character, and deeper faith in the meaningfulness of life."

        Lesser E. “Broken open. How difficult times can help us grow.” Villard, NY, 2005.

Elisabeth Lesser on "Change"

Self-awareness

     Communication is very tricky, even between siblings, never mind across divides of generations, cultures, religions, worldviews, etc. 
     Each of us on this planet can be compared to an individual cell in a multicellular organism. The health of the cell, the organism, and that of the planet, as we are slowly starting to realize, are completely interdependent. Healthy interdependence, in all cases, relies on excellent communication.
     The most fundamental communication occurs within each cell - and likewise within each of us. We can optimize this critical intrapersonal communication in various ways. The two with which I'm most familiar are meditation, and internal family systems.

     “the practice of meditation seems to prime brain cells to fire together in patterns that strengthen key brain structures – those, for example, important in tasks such as decision-making, memory, and emotional flexibility. And it may also improve communication among different parts of the brain in ways that further improve physical and emotional health."

     Salzberg S. “Real happiness – The power of meditation. A 28-day program.” Workman Publishing, NY, 2011.

Richard Davidson PhD, neuroscience researcher, 20 minute presentation:

No boundaries

     Our ability to keep attention focused on one person or one activity, for more than a few seconds, is surprisingly poor, and may be deteriorating.

     When busy with multiple commitments and deadlines, we typically only pay partial attention to the person or task at hand. A sizable portion of our attention is on what happened in the past, and what may happen later. The internet, emails, smartphones etc just compound our "continuous partial attention."        Ellen Rose's article: http://journals.hil.unb.ca/index.php/antistasis/issue/view/1390

     This way of being short-changes the person or task we're with, is very inefficient, error-prone, stressful, and makes us feel divided. We only feel authentic, and not surprisingly, we're only fully functional, when we're fully present.
     Can we really be professionally detached most of the day, then expect ourselves to be able to switch over to being whole with ourselves, family and friends?

     “I’ve always believed that if you put in the work, the results will come. I don’t do things halfheartedly. Because I know if I do, then I can expect half-hearted results. That’s why I approach practices the same way I approached games. You can’t turn it on and off like a faucet. I couldn’t dog it during practice and then, when I need that extra push late in the game, expect it to be there.”         Michael Jordan, NBA MVP 1988, 1991, 1993, 1996, & 1998.

     “Growth fundamentally means an enlarging and expanding of one’s horizons, a growth of one’s boundaries, outwardly in perspective and inwardly in depth. … Growth is reapportionment; re-zoning; re-mapping; an acknowledgement, and then enrichment, of ever deeper and more encompassing levels of one’s own self.” 
       Wilber K. No boundary. Eastern and Western approaches to personal growth. Shambhala, Boston, 1979.

Empathic engagement

     The therapeutic alliance between ourselves and our patients is based on trust and empathy. 

     “Accessing genuine compassion can sensitize professional caregivers to perceive, recognize and process information in a systematic and empathic way, guiding caring behaviours that support patients and families in their unique situation. Being present in this deeper way fosters a helping-trusting authentic relationship that is instrumental in supporting a healing environment.”

      Pipe TB et al. Building personal and professional resources of resilience and agility in the healthcare workplace. Stress Health 2012; 28(1): 11-22.

     "Empathy is grounded in the acknowledgment of death, the celebration of life, and rooting for each other to flourish and be." Jeremy Rifkin, author of "The Empathic Civilization"

Prioritization, Balance, Towards Living an Undivided Life

     The documented decline in idealism, and increase in cynicism, during dental & medical training is blamed primarily on heavy workloads.

     “Task saturation” refers to high-pressure situations, in which pilots must suddenly cope with so many things at once, that they lose their ability to prioritize, with potentially dire consequences. I first heard this aviation term in relation to the 2009 helicopter crash off Newfoundland, during which 17 people died. "Rearranging deckchairs on the Titanic" refers to task saturation. 

     We in health care are exposed to versions of task saturation, starting in university. Like overwhelmed pilots, we may take our focus off what's important without even realizing it. Because there’s so much to learn, we tend to ignore personal wellness / work-life balance during our studies. Then training is immediately followed by the rush to establish a career, start a family etc. By this time, a goal-oriented, workaholic lifestyle is solidly established. Personal wellness and work-life balance too often languish on the back burner - until we “crash”.

     It's wise and healthy to periodically reassess our lives and reset age- & life-stage-appropriate priorities. Everything around us is changing constantly. We need to check in with ourselves from time to time and re-vision where we are, what we're doing, how we're doing it, even why we're doing it. All of these are constantly changing as well. To lead an "undivided life", our outer life needs to be heading in the same direction to which our inner compass is pointing.

    Many of us "will never retire. I wouldn't know what to do with myself!" Some retire, then quickly go back to work - or - quickly die. Many others "are busier than ever" after retirement. Let's face it, most of us are like the old donkey that spent it's whole life walking in a circle, pushing a pole to pull water up from a deep well. When it was deemed too old to work and set loose by it's owner, the old donkey walked in a circle till it dropped dead. Donkeys are not alone in suffering from a lethal lack of imagination!
     See also: http://mindfulnessforeveryone.blogspot.ca/2013/11/432-i-try-and-i-try-but-i-cant-get-no.html