Tuesday, January 27, 2009

Best feeling ever. Ever.

I really shouldn't be making time to write this -- but I couldn't NOT write this. I want to remember the feeling I have right now for a long, long time. I'll keep it too brief to do it justice -- but it's better than nothing, I suppose.

Tonight I fully, truly felt like a coach for the first time within the borders of the state of Vermont. I want to capture what this meant to me -- so that at any point in the future, when I am in any way lacking in motivation or inspiration, I can look back and remember how this felt. Remember what gave me meaning and purpose.

Seven women. Barely 20. All with brand new HRMs in tote, HRMs they didn't have before they met me just weeks ago. Wanting to learn how to use them to empower themselves. To improve their hearts, their focus, their lives. I found myself rising to the challenge of which I wrote yesterday. I spoke slowly, clearly. With precision. What I said mattered in that instant, to them. I was almost painfully mindful of that. Instead of fearing screwing it up as I went (as I misfired in the last scenario I described in my last post), I approached it towards the pursuit of a good job -- just that -- and it made all the difference. I always tell people that it does, that the reference frame matters.

It really does.

One of my students is completely revolutionizing the way she sees the world, having run herself into the ground for YEARS -- as she was trained to do. I met her through the course I taught for indoor cycling instructors last term, and was impressed at how readily she embraced my completely contrary approach. She bought a HRM and is in the process of not only learning how to teach with it, but to re-invent herself through her own training. It's scary to completely uproot the expectations and prism through which you operate in your world. I heard her this time. I responded deliberately and carefully - specifically oriented to what (at least I think) she needed to hear right there and then. Could I have done better? For sure. And I will. But did I contribute something in the moment when I was needed to contribute? Absolutely.

Often you don't get to re-do the things you feel bad about -- and certainly not 48 hours later. But I did. Redemption is sweet. And I'll remember this for the rest of my life.

Monday, January 26, 2009


I'm a word junkie. For the better part of my life, I find myself latching onto fragments and pseudo-fragments that I instantly inhabit and just know will be with me for the rest of my life.

When I hear or read things that so deeply move me, I try my best to write them down - in lectures, meetings, movies, Spinning continuing ed rides (yes, right there on the bike... scribbling away; I actually have a 5-subject notebook mostly entirely full of thoughts and phrases that I use as coaching cues in my own classes). I've even been known to tell people during seemingly casual conversations that [whatever they just said] is going to be with me for a long, long time.

To be that moved by a mere string of words, to feel so deeply that something will remain with you forever, is a big deal. I've often wondered whether the sources of these words intended to have that much of an impact. My old boss, the source of words I thought would stay with me forever but faded long ago, absolutely did. He obsessed over making an impact -- and to some extent, he did... but not nearly as much as he thought he did. I have a major character in my life who often comes out with "lines" that dramatically impact my way of seeing the world on a pseudo-regular basis; sometimes I think he knows that but, unlike Former Boss, it's not contrived. One of my regular lecturers at school now aaaaaaaaabsolutely intends to make an impact through the specific words he uses -- and when he ever actually gets to making his point, I always *LOVE* what he says. He just takes 10 years to get there, and thus goes underappreciated by the masses. Failed intention. Intentionless success. A little bit of both.

This question of intention has prompted me, over time, to pay more attention to my own words. It's funny -- a lot of people in my "medical school life" (and to some extent, a lot of people in my non-medical school life) don't know the full extent of the somewhat ridiculous position that has unfolded for me over time. Having 400 people on a listserv who want to show up all over New York City to ride a stationary bike and hear you spout off about the "deeper meaning" of such a thing is actually insane. I didn't do anything to earn it; it just happened. It's the kind of thing that actually shouldn't exist. I know this. In theory, people shouldn't line up asking you questions about specific things you've said out loud in the throes of (cycling) passion. I know this. In theory, people shouldn't email you months later with the exact words you used about a given way of seeing the world. I know this, too. But it's been my life for the past two years. I don't talk about it even a fraction as much as I think about it (how do you even bring up something so CRAZY? How do you convey that you think IT'S a big deal, without misconveying that you think YOU'RE a big deal?). These relationships ARE big deal, to me, and a profound responsibility. There is a certain pressure associated with it - but not as much pressure as the rewards of knowing, with 100% confidence, that you can and ARE actually making an impact on another human being.

I don't have that kind of relationship with my new riders in Vermont -- not exactly, at least. I very much experience the "rush" of seeing, particularly in my 18-19 year old female regulars, the same look I get in my eyes when I interact with a pseudo-role model character. Is it enough to be contributing SOMETHING, even if for a moment? At first, it honestly wasn't. I had been spoiled by the suuuuuuuper-distorted set-up I had in New York, with dozens of people telling me crazy things about the exaggerated sense of importance of their 45 minutes with me a day (I'm allowed to call it crazy because 1) it is; 2) they know it, too; 3) I've related to a Spinning instructor that way myself). So, yes, crazy -- shouldn't exist. But did, and does no longer. Even without that, the past two weeks coming back to VT (after being so re-energized by the dynamic of my former life) have been REALLY rewarding. Those snapshots of "moments" of feeling like I was creating the energy I'm used to, structuring the specific experiences I intended, became enough. They are enough.

Over the weekend, I wasn't enough. A friend of mine, a friendship that came out of my Spinning classes no less, came to me with a difficult personal situation that represented an ongoing, thematic life challenge for her. She was vulnerable and in pain. She called up something specific that I said about self-empowerment during a ride when I was in NYC over my break, and asked how she could apply that to her situation. And I tanked. I just tanked.

While she said that she felt infinitely better after our chat, I felt like an infinite failure. Why? Because I knew that she didn't really hear me. I did not "wield my words with precision" (to borrow from one of my favorite life-altering fragments, from Jerome Groopman's "How Doctors Think") in a way that specifically met HOW she needed to hear it at that particular moment. Because of my inability to connect on the exact same wavelength of where she was RIGHT then, I did not structure a lasting moment for her. I did not inspire her to motivate herself towards change, to make a decision that she'd remember for the rest of her life. This friend was specifically, explicitly LOOKING for that from me right then. I had an opportunity, a moment, to say something precise that could help her to use her own mind clearly to tap into what she needed to think about, to prompt her to take a step back and identify what it was that she truly wanted -- all the stuff I talk about allllll friggin' day long -- and I blew it. I was generic and mediocre. I know I can't be a hero all the time, but I really wanted to be this time.

I think what went wrong here is that I was neither wearing my "coach" nor "doctor-to-be" hat, and I couldn't grab either one fast enough -- and when the question was I asked, I grabbed one of them and hurriedly put it on backwards and crooked. It was still on, I guess, but I wouldn't have wanted to pose for a photo with it.

This scenario will undoubtedly play out hundreds of times during my career as a physician. Selecting deliberate, precise words specifically directed to match the reception style on the other end. Often with wayyyyy higher stakes than I have to admit present themselves in a 45 minute Spinning class.

I'm seeing this play out with a family member now. This family member has declared that he is "cured" of his Crohn's disease (a lifelong auto-immune disease), and that he no longer has to be under the care of a doctor -- as per his surgeon who just removed half his colon. No. NO WAY. It's frustrating because I've spent 2.5 years in Crohn's disease research and have the unfortunate privilege of knowing a fair bit about it. A fair bit that makes this statement completely and utterly untrue. So either his surgeon is irresponsible... or my family member heard what he wanted to hear. Regardless of who is at fault, this is an absolute failure of communication. Imprecise words? Not connecting with the style in which the receiver listens? Not taking the time to verify a mutual understanding? All of the above?

All that matters are the words that people take with them when they walk out the door.

Today I got tearful in lecture (yes, again!). My course director scheduled a one-hour gap in lectures wherein he sat all 114 of us down and prompted us to sit and reflect about the course so far -- what we've learned (both content and process-wise), how it relates to REALLY what we're trying to accomplish, how it impacts the way we will one day care for patients. We were asked to write our thoughts down. Quiet reflection time... in medical school? It was a BRILLIANT perspective-resetting device, in the thick of this dense forest of "bugs and drugs" to memorize. "Something to climb for," as I would put it in a Spinning class. (As an aside, I actually did this a few months ago in one of my classes - gave people index cards when they walked in and asked them to write down what they wanted to accomplish that day. Prompting people to think about their goals is HUGELY motivational. I'm going to do it again with my Endurance ride on Friday.).

What did I write about, you might ask? About how, over the past 3 weeks of the course, I've learned HOW to be a liiiiiiiiiiiiiiiiiiiittle bit more precise. To start with a super-vague complaint ("I'm tired," "I'm pale") for which there could be 500000000 explanations -- and I've had to memorize a whole lot of stuff about those 5000000000 explanations, mind you -- and to gently chisel away at that bronto-burger of explanations through deliberate, methodical, precise questions and carefully selected tests. Do I know ANYTHING, in the big scheme of things? Not at ALL. But I surprisingly know... a lot. And being prompted to appreciate that is tremendously empowering and energizing to want to keep knowing more.

That's what I took with me when I walked out the door. And that's enough.

Thursday, January 22, 2009

"I think; therefore it is."

My old boss once said the above during one of his spontaneous mid-4-hour meeting "tutorials," this one on the spectrum of psychotic disorders. "'I think; therefore it is.' That's psychotic thinking."

But are there exceptions? Is there anything actually wrong with choosing to see the world x way, and believing deeply enough in that vision that it becomes the reality you inhabit? What we often chide as grandiosity might actually be a level of self-empowerment and commitment that many of us simply never reach.

I've spent a fair bit of time thinking, writing, and dialoguing about the concept of self-empowerment and self-efficacy over the past year. It's why I coach. It's what brought me to medicine. It's what makes me get out of bed every day -- to live it, and to spread it. It's the foundation of the research initiative I will be starting in the coming weeks (IRB-approval pending). It's the foundation of the book I plan to write one day. It's the most deceptively simple concept that stands as the deciding obstacle between "where someone is" and "where someone is going." That is, one's deep-rooted belief that one actually will get there.

A friend of mine once lamented that she was unable to stay on top of her life demands. When I recommended introducing a little bit more structure to her day, her response: "That won't ever happen. I know myself -- that doesn't happen." Of course "that" doesn't happen. Things don't happen. WE take actions, we create opportunities and constructs. We are the agents of action; results are just... results.

I coached a ride the other day that I called "The Impact Ride." (Yes, Spintastic readers... I'll write up the profile over the weekend. I've forbade myself from investing time into both blogs in one shot!). The concept was tapping into SOMETHING that each person wanted to do -- large or small -- and identifying its specific personal meaning, and its associated concrete steps and obstacles. Once that was identified, the task was to establish pure control over one's attitude and belief in themselves to do that thing that gave them a sense of purpose. We accomplished that through technical control -- biofeedback, essentially -- over breathing and heart rate; and then, we applied it towards that larger goal. That is, the power to have impact on one's self... and what that means for one's power to have impact on the world.

It was special to me. I debuted it on my 25th birthday. My birthday is a huge deal to me -- it always has been. It's not because I want to be acknowledged or celebrated, actually, no matter how much of a "validation junkie" I am on my non-birthday days. Instead, it's because the "event" serves as a regular marker to take stock of my own impact -- on myself, and on the people around me -- and, accordingly, I like to be surrounded all day (physically, emotionally) by symbols of that impact. The friends -- and even relative strangers -- who value my presence in their lives, and take time out of their day to tell me so. The people in my cycling class who don't even know it's my birthday but whose tear-brimming responses become my favorite part of my day. The characters who inspire me, for reasons great and subtle.

It's even an opportunity that triggers me to appreciate when my energy and time has been wasted. Identifying drains to one's energy and spirit is often just as important towards the creation of a meaningful balance -- to me, at least. Energy is a finite resource; and yet it's sub-deserving targets are often "tolerated." I talk about this a lot -- I even had a segment of my New Year's Ride devoted to it; and yet, I'm guilty of tolerating drains to my energy indeed. I am grateful for the prompt to make an impact on my own life by removing anything that reeks of "settling" or "tolerating."

I think; therefore it is.

There is a profound power behind the belief in one's ability to decide how the world should and will be, and what presences and experiences will support the creation of that world.

One of my many many interpersonal challenges as a physician will be to tap into whether a person HAS a vision of their world -- and, if so, what it is. That needs to be the starting framework for EVERYTHING.

I attended a presentation last week by a woman and two men who lost their spouses to cancer, and had been their primary caregivers leading up to their deaths. They shared their experiences with their loved ones' healthcare teams -- what worked, what didn't work. They remembered physicians who were emotionally and psychologically "present" with them during their families' struggles. They remembered how news was delivered, how hope was fostered and squashed. "Hope," which takes on a spiritual component for many people -- not necessarily for me -- is a fascinatingly complex concept. I read a wonderfully inspiring book, "The Anatomy of Hope" by Dr. Jerome Groopman, that explored this topic from perspectives of patients and medical professionals. It didn't exactly resolve anything, but it sure got me thinking. Hope seems to most directly present itself as an outlet for positive thinking in the face of despair. But why wait for despair? Is "hope" not just a belief in achieving a desired outcome -- whether that outcome be entirely within one's control or not? But having the perspective to identify which outcomes ARE within one's sphere of control -- and having the resolution to invest in it, to inhabit it -- that is self-efficacy.

I think; therefore it is.

Thursday, January 15, 2009

Putting it All Together

2008, in a lot of ways, was the year that things started to come together. Most of my central defining components of my identity and the way I see the world didn't exist before 2008, as shocking as it is to appreciate the magnitude of such a drastic overhaul. I became a coach, as opposed to a "mere" instructor. I became a physician-trainee, as opposed to an overly ambitious pre-med. I inhabited the belief that I can definitively "structure (my own) experience" (to borrow from one of my go-to meta-coaching phrases) to create a truly compelling, meaningful existence.

In 2008, I declared many seemingly crazy things:
1) I would quit my stable, salaried, well-connected job with steady hours, steady benefits, and steady security. I would become a full-time fitness professional, and scramble to bill out enough hours between coaching and my contract research gig (and some random pizza marketing -- only in New York!) to be able to eat out 4x a day, pay (most of) my bills, and travel like mad.
2) I would end my relationship with the man with whom I thought I'd spend the rest of my life.
3) I would entirely swear off all things that did not either a) make me happy, or b) in some way contribute to my life.

All three of these variables came together to prompt the ultimate reinvention. Each, in its own way, served to instill a belief that I could, and would, declare that the world is x way "because I said so" -- and to take it a step further and "make it so." That is absolutely how I see the world -- and, psychotic or not, find it exceptionally adaptive.

Still, 2008 wasn't perfect. Something was missing in My New Life -- and I was able to recognize it because it was something that I actually HAD in My Old Life. Building coaching relationships -- being "that" resource for someone, playing a central role in empowering a human being to take control of his or her life through a reinvention of life outlook and self-talk -- are some of the most valuable experiences I've had to date. And I didn't feel like a coach here; I regressed to being a Spinning instructor. The distinction meant something to me, and it meant a void -- a void that discouraged my creativity and my passion. I've been moved to take certain initiatives, both in my "coaching" world and in my medical world, and NOT followed through -- because of a certain dampened belief that my world would be the way I said it should be, to some degree.

So when I kicked off 2009, I owned up to that -- and vowed to nip it in the bud. 2009 would be the year that the world was absolutely the way I said it was, because of my supreme ability to control my attitude and the "lens" through which to view every experience and opportunity. In coaching myself over the hurdle into the new year, I effectively became a coach again. I see the difference in the way I teach now, in the conversations I'm now having -- just like the ones I've had all day long in New York.

Today, as a whole, was magical. A lot of things came together.

I got some faculty support today for a research effort I want to initiate -- which magically melds my Old World (and its characters), with my New World (and its characters). Looking at the relationship between heart rate monitor use and global self-efficacy. More soon.

I diagnosed my first patient today, based on a detail I held really important, that probably isn't THAT important. For the first time, we had a standardized patient with a vague complaint ("I'm tired.") -- and we have to figure out what it is via questions, examinations, and labs. HUGELY open-ended. I was surprised at how much I was able to assimilate stuff I learned in the past 6 months. It was tremendously empowering, not as scary as I anticipated. I learned last week about some food/drug combinations that inhibit the absorption of iron from food - including dairy and tannins in tea. I feel very strongly about this fact, as I appreciate how very few people "out there in the world" appreciate this fact. Even when I was iron-deficient anemic, my own doctor never told me this stuff. Anyway, my standardized patient was pale and tired. I asked a bunch of questions, but ultimately got focused on the area of diet and particularly what he was eating with WHAT. I asked seemingly weird follow-up questions, and learned that he was drinking a lot of milk... with his meals. HUGE. Some of the lab data didn't make complete sense. My training partner thought I was making too big a deal over this., but I wouldn't let it go.

I was right. Iron-deficiency anemia secondary to poor oral absorption. What a rush to solve a puzzle... and through a personally gratifying pet detail.

I coached a pretty amazing ride tonight. I'm going to write about it on Spintastic tomorrow, so not going to elaborate for now.

I had a challenging drive to a meeting this AM for my charity cycling event. I felt like a real driver, in control of getting from A to B... instead of just hoping for the best.

It was a real day of things coming together. And it felt fantastic.

Thursday, January 8, 2009


"Reflective practitioners can identify and interpret their own emotional responses..., can make sense of their own life journeys, and so can grant what is called for - and called forth..." Rita Charon (2001) Journal of the American Medical Academy 286(15):1899

I saw (a version of) this quote and was immediately inspired to write, consistent with one of my 2009 new life policies that I indulge (most of) these inspirations when they strike. Sometimes I'll write on Spintastic; sometimes I'll write here. But I will write. To kick things off in my epic New Year's post on Spintastic, I actually outlined -- more for myself than for either audience -- the difference between the content and style of the two blogs: here, there are no rules. I don't need to be articulate, or even literate. I can be outright psychotic if I want to. I have permission to rant and rave and tell anticlimactic stories. Spintastic, some people look to for inspiration -- and there is a certain pressure associated with that. No pressure, no expectations here. Just "identifying and interpreting (my) own emotional responses.... making sense of (my) own life journey" -- so as to, one day, be able to call up those responses and clarity when I need them.

I've been spending some time lately with a new character, which has prompted me to think about the art of self-presentation. I enjoy meeting new people -- people are fascinating and, accordingly, so is finding out what makes them tick. However, I have never enjoyed the process of people getting to know me. It's a lot of pressure - the strategic task of actively selecting the details and stories that most accurately paint a picture of what it is that makes me "me." I wish everything could just be KNOWN: everything I've seen, everything I've thought about, everything that's important to me. That's not how it works, of course. I find myself now sharing some thoughts that weren't very strategic at all -- that may or may not have actually achieved the desired effect. I was okay with that, okay with letting it all unfold. I had all the time in the world -- and if it didn't unfold in a way that was stimulating and compelling to me, so be it.

Today, I appreciated how different a first-time encounter is when it takes place in an examination room and not a coffee shop.

Everything's different: the goals, the rules, the expectations.

One would assume that the clear distinction is that doctor/patient relationships differ in the goals - from a mutual "get to know one another" to a one-sided "doctor get to know what's wrong with patient." I don't buy it. So much is variable...

I am wired to aim to understand the person before me -- what makes him or her tick, what goes on in the world outside this exam room (and I am lucky to be training in a program that prides itself on this same orientation). I am wired to aim to form a partnership, a "team effort" to build this complex and complete understanding as the backdrop of all the conventional "medical stuff." Many patients, especially younger and educated people, are all for it. They strive to be empowered in all realms of their life and, the way they see it, their health care should be no different. Damned straight. But so many people reject this construct -- whether that be because they outsource all the other aspects of their lives and automatically default to that option, have a distorted view of the "wise and mighty" doctor in the white coat, don't think they have the capacity to play a proactive role in their care, etc.

Many people also auto-filter the aspects of their lives that are "relevant." So right there, that one-sided "get to know you" goal is not as clear as one would think. It's not, "Here I am." as much as "Here's-the-part-of-me-I-think-you'll-find-relevant."

Conversely, the same principles and techniques developed for dealing with these challenges in clinical medicine do lend themselves nicely to casual interpersonal encounters. Altering the expectations, embracing the blankness of the slate... resolving to be ok with being unresolved.

I started this a week ago and don't remember where I was going with this. But maybe that's the point.