Thursday, May 21, 2009

The Power of Structure.

He reeked of urine. He required two people to dress him in his three layers of supportive socks, weather-inappropriate suit jacket, floppy fisherman's hat, and velcro sandals. He was on more medications than could be counted on his badly arthritic fingers and corn-ridden toes. His heart had been threatening mutiny for the last ten years.

By all objective accounts, he was falling apart. And yet, I can't remember the last time I witnessed someone glowing with such utter delight.

I accompanied my preceptor to see this patient, a sweet elderly man whom I had met last week when he came in with a painfully debilitating injury. This time was a totally different story. He was completely overjoyed to be there: his face was aglow, his lips parted over his teeth as he giggled with pleasure. I identified that most of this display of pure happiness was secondary to him clearly thinking the world of my preceptor -- but even through my lame concussion-induced fog, I could see a few other factors at play here. One, his appointment got him out of the house; two, my preceptor empowered him by encouraging him to use part of his visit as a forum to talk about the routine (social outings, ritualistic sets of stretches and walks) he had carved out for himself, that quite evidently gave him a true sense of pride, accomplishment, and purpose at this point in his life. I complimented him on his diligence (I really was quite impressed...), and asked him to tell me the story of how he came to start exercising. His eyes sparkled as he recounted his evolution from sets of 5 to 150, and how much he looked forward to starting off each day with his regimen. Mind-blowing. Talk about commitment to improvement for the sake of improvement alone!

Structure. Routine. Order. Purpose. Whatever you call it -- it all comes back to self-efficacy, that ever-important part of one's schema for navigating the challenges of one's world.

A few hours later, we saw a man who brought in his Excel spreadsheet logging his medications, their indications and dosing instructions. That was his structure, his way of establishing order and control over his world. Did he feel completely at peace? No. But it was something.

I have the privilege of coaching people who have somehow decided to make ME part of their schema for structure. I have the privilege, too, of observing the positive outcomes in their global well-being-- not necessarily because of ANYTHING I do or say or suggest. Sometimes there is something to be said for structure for structure's sake alone. Sometimes a little structure just affords one the opportunity to use one's mind juuuuuuuust a bit more clearly.

I've personally been a Structure Junkie for as long as I can remember, evolving from pathologically rigid compulsions to healthy goal-directed balance. The key to my gradual adjustment to medical school, in fact, was arriving at a specific structure wherein I tended to my academic needs but blocked off specific, reserved time for my training (for my 6-Hour ride), for my writing (perhaps too much time...), for my mindfulness practice, for my maintenance of important interpersonal relationships, for my aaaaaawesome time at the clinic, for promoting my HR Monitor study, for even crazy things like sleep and pleasure-reading. Everything lined up quite neatly, and I felt exceptionally stimulated and rewarded -- learning, growing, contributing. When I deviated from that structure (i.e., my 6-Hour ride was over), I've not been 'on top' of ANYTHING, really. After a month of puttering around lamenting The Structure That Was (conveniently in the context of iron and vitamin D deficiency, to complicate matters), I decided that this simply isn't going to fly anymore. I need my structure, my specific routine for investing in my well-roundedness and clarity. Without it, I don't do ANYTHING well -- including the study of medicine. First major action: I have officially registered for my first outdoor Century (September 26) -- that is, again, something specific for which to train that is slightly outside my comfort zone (to make it meaningful to achieve) but TOTALLY masterable in a specific, short-term way. I would distinguish this from medicine; I will spend the rest of my life learning and learning and learning and learning, and never "master" it -- and especially at this stage of my training, I am a master of ABSOLUTELY NOTHING. I'm okay with that - but I absolutely need to balance my mediocrity with something over which I have complete control over getting really friggin awesome at, relatively quickly. Practicing commitment to improvement, and quantifying the results of my efforts.

One of the exceptionally gratifying aspects of the project on which I am working this summer is that I will get to tap into my appreciation for the merits of structure -- both for myself (all of the sub-projects I am coordinating already have a color-coded Excel spreadsheet... obviously), and for the patients whose care we are striving to improve. Our efforts to measure and enhance health literacy by empowering patients to play a proactive, equal role in the partnership with their physician are going to boil down to one thing: STRUCTURE. Structure specifically tailored to an individual person, based on their needs and values. At the most basic level: What medications do you take, for what, how much, and when? Balancing an effective starting point for ANY meaningful dialogue about safe, effective treatment with the specific communication approaches to which a given patient will be receptive to learning how to contribute to his or her own health care. Inhabiting someone's existence, connecting with their story. Learning enough to devise a framework, a "structure," through which to exchange information.

Recognizing that it's not enough to give someone a script for x drug and hope for the best, taking the time to carve out this structure -- this way of making sense of the world -- for someone is what is going to keep them safe and contribute to mutually established treatment goals.

And it's going to be awesome.

Friday, May 8, 2009

"Flaneuring" to... Purpose?

2AM. Cruising down the deserted streets of My Really Old Life in a cab. Some familiar; most not. I couldn't remember what it had felt like to be that version of myself. And it didn't matter.

I took a week off from medical school (like ya do...) to accompany my preceptor and another clinician from the clinic to a conference in Washington, DC relating to the quality improvement/patient empowerment project (as part of a federal government initiative to enhance clinical medication management) with which I'm helping them this summer. I hadn't given much thought to the symbolism of returning to my former stomping grounds (I did my undergraduate studies in DC) in the context of an entirely different life. But there in that moment, it's all I could think about. Almost five years to the day of addressing my class at our college graduation about "the road ahead," I'm on a road is so drastically, insanely different from anything I'd ever conceived of existing -- let alone being on it. I've appreciated that I do things, that I've done things -- but somehow, layering on the perspective that so much has unfolded in just five years, layering on the context of this specific project with these specific characters, my appreciation just EXPLODED.

Upon starting my new life in Vermont, I vowed to work hard to manage my expectations -- that is, not to impose the constructs of My Old Life, not to skew or constrain my new experiences in any way. Just trying to take it all in as it came. Yes, I'm on a dirt road with a sign labeled "DIRT ROAD." Yes, there's a baby lamb walking around the dinner party. Yes, that milk just came from your cow. Just taking it all in. Mindfully and carefully attending to each detail: paying attention on purpose. Fine-tuning my abilities to observe through multiple senses, differentially processing these observations, learning when to interpret and when to just tuck the raw granules away for when I need them.

Still, it was hard to be open-minded as we began this trip, as I was consumed by my fear and perceived inadequacy. My standard self-imposed pressure to not say or do anything inept for a few hours once a week would be magnified beyond belief: 72 hours of opportunity to look like an idiot -- or worse, a disappointment. When I feel out of my element, I fall into "Lame Mode." I get awkward. I stutter. I shut down. I'm a version of myself that is incompatible with my ability to "take it all in" -- to take anything in. I miss out on opportunities to soak up the subtleties of the experiences around me, and I so very much regret how needless this loss always is. So in embarking upon this trip, the only expectation I imposed upon myself is that I would obsessively focus on NOT falling into that mode. I would "adopt the character" of being Me, all the time. That could mean I'd say something cheesy, something blatantly absurd -- but that would suddenly be fine, so long as I was comfortable enough being "Me" to perhaps even forget that I was faking it.

When I started this blog, it was never with the intention that anyone would read it. Over time, when I started to appreciate that 100+ people did, I started writing differently. I internalized the responsibility of writing for an audience, like I do on Spintastic. But "Life" isn't going to afford me the opportunity to describe key background points (I did take a week off from medical school, after all...), but I do want to capture aspects of this experience that *I* need to process before I get to work. My apologies for the lack of clarity and/or coherence.

This week was one of the most formative experiences of my life. It marked a fusion of seemingly EVERYTHING that has ever been important to me, even things I'd forgotten were important to me. Reconnecting with my life as a project manager, welcomed as an equal collaborator by two people I deeply admire and respect, using the life-theme about which I am most passionate (that is, patient self-empowerment and self-efficacy) as a vehicle for accomplishing something important. Achieving gratifying rewards along a continuum of improvement -- subtle, almost indistinguishable changes, sustained by how gradual they are adopted. "Increase and breathe" at its finest. Kaizen, the Japanese business philosophy concept after which I've based SO many Spinning rides and even named my car! Breathing life into the abstractions about which I spend more time thinking than doing/learning/behaving responsibly. By forcing myself to verbalize and advocate my way of seeing the world in a context that intimidated the hell out of me, I inadvertently developed an entirely new level of confidence in these thoughts typically reserved for the context where I entirely call the shots (i.e., this blog).

What this project is going to mean is getting people excited about the stuff I think and write about all day long. Empowering patients to be equal players in their care partnerships, ensuring that they have the information they need in the context they need. Quality control through communication, a concept that I most love about the clinic's practice model. It's going to mean transforming myself from the 'tag-along, completely useless mode' that I'm not at ALL used to playing (med school makes me wish that I'd never had a pre-med school life, so that I never got accustomed to being useful!) into a mode where I can use specific skills from My Old Life that used to make me feel so rewarded -- and in so doing, transform my abstract thoughts about patient care into concrete, measurable aspects of human beings' experiences. Huge.

There were so many moments this week that I'm going to remember for the rest of my life.

I told my preceptor how inspiring and influential to me he was to me, consistent with my "life policy" of letting people know -- with great specificity -- why and how I appreciate them, but having never yet been comfortable enough to share with this character. I wasn't specific -- but it was a starting point to express my gratitude. I've written here at length about moments with him and his patients that will forever change how I will practice medicine, about stylistic points and qualities that empower me to learn and do and grow. I didn't 'go there.' But I think that at least to break into a comfort level of acknowledging that I am inspired, and to say thank you for it, was an important point for at least MY end of this mentoring relationship. I'll be able to learn so much more, and to learn differently, now no longer inhibited/distracted by my own nervous energy.

What inspired me to do this was a conversation we had about patient empowerment. I was so mindful of how DIFFERENTLY he saw the world as distinguished from any other doctor with whom I'd interacted, both personally and professionally. So I stopped keeping my thoughts to myself -- my thoughts about how the word "compliance" makes me sick to my stomach, how I see the world as a collaborative development of strategies to accomplish x treatment goals. I'd never said that stuff out loud to a doctor before; I knew that this paradigm would dictate how I'd care for my own patients, but somehow lacked the confidence to verbalize it to "someone who knows how it is." Almost like I feared being rejected or dismissed for my naive idealism. Though we'd not had this dialogue previously, one of the reasons I admire this character is that so many things he says and does reflect this paradigm. But verbalizing my values, and having them explicitly validated by my mentor, was huge.

At one point, I detected that I was being awkward and shy and non-participatory. I decided I needed to shock the hell out of myself to break out of it. So I decided that I should stand up and ask a question in front of hundreds of people. Before I did it, I could feel my heart rate shoot through the roof -- louder, faster, harder... like I was sprinting in my chair. Breathe. Rehearsed the strings of planned words in my mind, heard them slow and composed. I delivered it exactly as planned. And you know what? I stopped being awkward/inhibited for the entire rest of the trip -- and not just because I drank more wine in a 48 hour period than in my entire time as a Vermont resident. Though that was helpful, too, of course.

Last night, I told my preceptor about my traumatic departure three years ago from my once-consuming former career -- the melodrama, the toxicity, the pain. I don't talk about it or think about it much anymore -- it's been so long, and so much has taken its place in RAM. But I do think that people who don't know about that part of my life never truly will ever fully understand me -- perhaps they can understand me well ENOUGH; but never completely. I reflected on aspects of the experience that I REALLY hadn't thought about in a long time -- developing creative management styles, tapping into motivation to 'prove' something (given how unqualified I always felt -- note the parallel to medical training!), successfully evolving from blind "hero worship" to selectively connecting with specific thoughts and qualities that inspire me. There are indeed so many pathetic, sad details of this story, of course -- but I wouldn't have changed a minute of it. I am uniquely qualified to live my life because of every experience I've taken in, for good and for bad.

"Did you ever get closure?" he asked. "Tell me a happy ending..."

It was right there, unfolding moment by moment.