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.

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