Friday, July 31, 2009

Coaching Yourself.

I tell the people I coach that my job is to teach them that they don't need me. By suggesting the short-term and long-term merits of learning to "coach one's self," selectively soliciting and incorporating incoming stimuli along the way, I pride myself on my ability to empower people to make their own training choices... and to observe how the skills they build through their athletic training can be applied to the rest of their lives.

I write frequently about how readily this approach lends itself to medicine. The single mom who struggles to quit smoking. The isolated widow who can't bear to leave her home. The dairy farmer who can't seem to change his diet enough to get his blood sugar under control. All of them learning to make choices consistent with the pursuit of a goal that means something to them, and why. All of them learning to direct their self-dialogue. Learning to direct their lives.

This morning I had the unique opportunity of observing an EMDR (eye movement desensitization and reprocessing) treatment session where I was able to not only see this very concept play out -- but to actually contribute to its synthesis. EMDR is an evidence-based treatment for Post-Traumatic Stress Disorder (PTSD) that has been in my archives of "stuff I know that exists without actually understanding how it works" from my psychology training. The basic concept is bilateral brain stimulation (through tactile stimulation of the fingers and visual stimulation by eye-tracking back and forth) in a safe, present-moment construct that allows complete processing of a re-experience of a traumatic memory. The idea is that PTSD results from incomplete processing of a distressing event -- and so, here, that processing can be brought to completion while attaching to it new, adaptive neural pathways.

The woman who graciously allowed me into her world to experience this technique likely did not appreciate how rare of an opportunity she was affording me. What I crave more than ANYTHING is the opportunity to observe management of emotional symptoms besides drugs. I want to see people who are brilliant at it; I want to see people who suck at it (that's how I trained myself as a coach, and that's how I'm training myself as a medical student -- abstracting things to emulate, and things to be on the lookout to avoid). The trouble is that, understandably, nobody wants an "observer" (medical student or not) during visits where they plan to discuss emotional symptoms with their doctors.

In the basement of the clinic where I'm training, tucked away in a dark little corner, is one of the only EMDR specialists in Vermont. Very few people know what she does; very few people seem to even care. So I decided to introduce myself, tell her that I'm fascinated by what I think she does, and that I'm frustrated that my medical education doesn't teach me anything about her world -- so, could I observe? The therapist gave me a hug and called a ton of abused, traumatized women and asked if a stranger could be brought into their worlds and hear their deepest, darkest secrets that they've barely processed. And some of them actually said yes.

So there I was, in this tiny dark corner room, as a participating audience member in the theater of a human being's life. 45 year old single mother, six years clean from all sorts of substances (IV drugs, alcohol, and who knows what else?) still struggling with her recovery, while experiencing PTSD from a 15-year history of physical, sexual, and emotional abuse by men in her life. And there I was, breathing in the privilege that was this woman trusting me with more pain than I've ever seen before.

How the EMDR protocol played out was to process a given issue (like would be expected in a psychotherapy session), wherein the therapist targeted a specific theme and message for self-dialogue and engaged these brain-stimulating techniques to more "deeply encode" the thought. Then, the patient was prompted to describe the emotional and physiological experiences that resulted from the newly processed thought. I imagined that, in a former life, this woman had probably not been so expressive -- that what I was observing must have been the result of a LOT of work.

After an hour, I saw a woman who was empowered by her own thoughts. So when it was my turn to speak, I called her on it.

I told her that I deeply admired her strength in "coaching herself" through her adversity, and how impressed I was by how far she's come and how committed she is to seeing herself through the challenges that lay before her. She started to cry.

"Nobody's ever told me that before. I guess I really am coaching myself."

We said goodbye. After the door closed behind her, I started to cry, too.

Tuesday, July 21, 2009

Meaning "Something."

His eyes darted back and forth, tracking nothing. He grasped reflexively, mouth agape. Tubes connected his gut with a bag, his airway with a honking block of metal. A honking block of metal with an on/off switch next to my foot. I dared not make any volitional movement, lest I trip or bump or in any way interact with that switch.

Persistent vegetative state was his diagnosis. He wasn't making any volitional movements, either.

My new friend, a 4th year student doing a rotation at the clinic where I'm working this summer, and I made a house call to check out a potentially infected stoma site of a 39-year old man who'd been this way for the past 2 years after blowing off the top of his skull in a welding explosion, with exceptionally poor prognosis of regaining any function whatsoever. His parents cared for him on their own in their home, and fervently believed that he'd walk among us any day now.

"I ask him sports trivia and ask him not to blink for one choice, and to blink for another. He doesn't blink at the right times." the mother told us. "And I read all about them stem cells. Stem cells, that's the trick."

The man's father, a stoic crusty old Vermonter, became tearful as he recounted to us what their family had been through since the accident. We stood before his rickety old porch, looking out onto his vacant, barren farm. Tattered laundry strung past us on clotheslines. The early evening sun's glare blinded me, though not enough to miss the quivering lip and glistening sadness of the old man's eyes.

I have never felt so useless. I'd not been asked to do anything or say anything, or in any way make any mark on the situation I was taking in. But the fact that I literally lacked the capacity to interact with the world around me and its instant characters -- it paralyzed me.

My colleague, though, was brilliant. He had all the'right' things to say. The easy small-talk, the gentle balance that allowed him to neither crush nor inspire false hope. I was inspired by his confidence, his charm -- inspired in a way that somehow seemed more "accessible." He has two years more training than I do; in a mere two years, would I be able to carry myself as he did? I doubted this very much, though it inspired me to ponder the possibility of carrying myself with such grace.

This moment captured what much of my time at the clinic this summer has been about. Lots of ideas circulating with little forward movement. Not accomplishing much, feeling generally useless. Not feeling like my presence has been serving a purpose. I linger in hallways, awaiting an opportunity to demonstrate my utility. I pace anxiously. When I get sick of myself, I invite myself to tag along to observe a patient visit (like I used to do, before I started this medication safety project to meet with the miniscule number of patients who bring their meds with them to the clinic) and feel more connected. Beyond the two such visits I do per day tops, I manually type out long Excel formats into color-coded cells that spit back data that nobody really cares about. I know that I will redo every single one of those formulas in an order of mere weeks -- and yet, I type over and over and over again the tedious characters, as my one shard of remaining hope to avoid being perceived as idle and initiativeless -- trying to carve out a specific role that may or may not actually be needed. Even the patients with whom I meet don't necessarily believe in my function. It's hard to psyche myself up for it, even if I believe in it -- and hard to get anyone else in the clinic psyched about my function, since I'm so sub-enthusiastic.

So imagine my surprise when a nurse sought me out to ask me if I wanted to meet with a patient who was specifically coming in to talk about her medication concerns, and bringing her 20 meds in tote.

63 year old woman with a 35-year history of treatment-refractory major depression. She looked down at the floor, evading eye contact. She answered my questions with curt, one-word replies. She brooded and sighed, hunched over herself in the chair beside me. I introduced myself to her and described what I was going to try to do for her.

She started to cry.

"I'm so scared! I'm on all of these medications and they're too many, and I'm so scared!"

My major life-upgrade during my first year of medical school was to take up reading for pleasure. One of the most insightful books I've ever read, Prozac Nation by Elizabeth Wurzel, described a young woman's lifelong struggle with major depression. Not in a rote, cursory, cliche way. Raw, painful. Ironic. I inhabited the author's existence, practiced anticipating the consequences of the way she saw the world, and painfully observed how simultaneously rewarding and discouraging it felt to get good at this sort of anticipation. Sometimes I wonder whether I should spend more time studying and less time doing the stuff that most med students don't do. Today, I was so mindful of how this book specifically prepared me for this specific moment. I 'got' it. I was there. I connected.

I spent 2.5 hours with this woman. I asked her to talk about what it was like to wake up and move about, and dress and eat and get about her day. I asked her to talk about what it was like to leave the house, to interact with her family. To go food-shopping, to attend church. To process the world around her. To communicate with her doctors, her therapist. To feel alone, discouraged, purposeless. Hopeless.

I waited an hour before I brought up her medications; I needed her to trust me first -- and, unlike an actual doctor, I had all the time in the world. I asked her if it'd be alright to go through each medication one by one, to make piles of the ones she thought were helpful vs. the ones that she might want to revisit. I wanted to empower her to appreciate that she was in the driver's seat, that she had complete control over the elements of her world. She was willing to humor me, at least.

By the end of 2.5 hours, the woman acknowledged that 10 of her 20 medications "definitely" were helpful to her. That was a big deal. And along the way, we tapped into issues that I wondered whether they'd seen the light of day before -- her anxiety about how she communicated with imprecision, about remembering certain key things in her day. I didn't know how to manage her meds; she probably really did need all 20 of them. But I knew about her anxiety. I've not had any training -- but I knew EXACTLY what to say, how to prompt her to evaluate her thought process.

Everything out of my mouth was fluid and confident. I knew that I knew what I was talking about, and I just did it. And she did it. She engaged the questions I asked her, engaged the concept of asking herself questions, of rehearsing her coping mechanisms in advance of encountering challenges, of developing an arsenal of experiences to draw upon that demonstrate her strength and confidence.

As each word passed my lips, I line-item compared it to those that have spouted during Spinning rides, blog posts, car rides, and all of the other opportunities I've given myself to practice, inadvertently, for this one moment.

As I deliberately carved each word to empower this woman to motivate herself towards change, with the exact same words that I'd used for so many literal and figurative hills for myself and others, I was so mindful of how directly I was speaking to myself just as intently as I spoke to the woman before me.

This was what I had trained for; this is what I had trained myself for.

I made her a list to take home with her of three skills she had developed and practiced during our time together. Her ammo against her depression that was all of her own active creation, to help the meds work better. Her way of reminding herself that she was in charge, actively constructing her own experience.

She smiled and took my hand.

And I knew that I could and would never practice medicine in any other field besides primary care.

When I departed her company, I got tearful. I'd never felt so useful. It wasn't any particular skills or talents -- this really WAS just all about having unlimited time in a setting where time is a finite resource.

When I presented what had happened to the clinic's director, her physician, he was more amused than anything else -- apparently this visit theme was something of a pattern ("complain about meds" --> "threaten to stop meds" --> "come to admit that most are a good idea"). I felt a bit sheepish at first. But I knew that in 2.5 hours of truly connecting with a person who avoided and denied connection, this wasn't just more of the same. It had to have been different.

It didn't need to mean everything. But it needed to mean something.

And even if it were only to me -- for once, that was enough.

Monday, July 13, 2009

Synergy, Balance and Purpose.

The past year of my life has been all about carving out an existence of synergistic balance between the "physician-in-training" and the "coach" realms of my world. I used to conceive of them as separate but complementary compartments. Separate demands, separate skills, separate liabilities. Separate blogs.

I've always said that medical training makes me a better coach, and that coaching will make me a better doctor. Medicine compels precision; coaching, connection. Each tapping into the specific relevant aspects that give people meaning and purpose -- just, differently. I had to find a way to invest in both compartments, as each has so much to contribute both to where I am now -- and where I will be. But if this year has been about nothing else, it's that I've learned to stop making this distinction at all. I don't merely "switch hats." I just AM.

And what has this new approach meant for me?

As a Coach
I coach the way I'm going to care for patients. I present training sessions that consist of choices, educate people as to the contexts for those choices -- and then empower them to make those choices in a way that is consistent with their goals and values. The language I use is more collaborative. I ask more questions than I ever did before. I ask people to ask themselves questions, to be agents of change and investment in their lives. People new to riding with me often observe that it's rare that they attend a Spinning class, for example, where the instructor is not telling them what to do the entire time. I've now gotten comfortable explaining my approach, and how it fits into MY world.

The other day, a woman in an NYC class I subbed was executing all kinds of safety-contraindicated stuff: mashing her legs, cranking the resistance too heavy to even turn the flywheel, letting go of the handlebars. As a life policy, my interventions begin with general guidance to the group. This is usually sufficient; "offenders" often hear what I say, appreciate the inconsistency between what they hear and what they are doing, and make the appropriate adjustments. If this fails, I describe my corrections in alternate ways. If this still fails AND I think this is a major safety risk, I mute my mic and approach this person individually. As a sub, my threshold for individual intervention is pretty high -- I'm more concerned with pissing people off and inspiring them to cause a scene. So after 6 or 7 "group" interventions and very unambiguous "this pertains to you" signaling, I gave up. I knew that speaking to her privately during class would likely alienate her, and wouldn't actually have an impact on her training practices once I walked out of the room and out of her world. I couldn't make a difference, so why bother? I gave up on her.

Then I remembered that I wasn't wearing a particular "hat." I was just ME, the cycling coach who knows what the hell she's talking about, who also just so happens to be training as a physician. Time to start acting like one.

I'd given up on this rider who ignored my educational pleas for health and safety. Just like a doctor giving up on an obese, hypertensive patient with Type II diabetes who eats terrible, drinks too much alcohol, smokes, and doesn't take his or her meds. That's what I just did. I didn't find a way to connect, so I blamed this woman as "refractory to cues." No. I just didn't find the right cues. Yet.

At the clinic where I'm working this summer, I'm running a survey that examines patient attitudes towards medications, taking medications, their involvement in their treatment plans, etc. I included an open-ended question that probes patients' reasons for skipping doses of meds. It was my goal to demonstrate that mismatches between patients' goals/values and the regimens prescribed by their providers, or misunderstandings/miscommunications mattered. That calling this phenomenon "non-compliance" is a cop-out -- and that by asking people a really basic question about their obstacles to a desired outcome, we can learn from this and improve said outcome.

Could I apply what comes so naturally to me in medicine... here?

After class, I approached her.
"Hey, I notice you have really strong legs and a great pedal stroke," I said to the woman.
Her eyes perked up.
"But let me ask you something. I notice that you often let go of the handlebar. I'm always interested in the thought process of the people who take my classes -- when you do that, what goes through your mind?"
"Oh, well, I'm pregnant -- and I don't like reaching over. It's uncomfortable."

HOLY shit. Really? That's all this was about? Turns out, non-compliance doesn't exist on a Spin bike either.

Now I understood her obstacles to heeding the information I presented; now I knew how to frame my message in a way that was consistent with her values. I showed her how to raise the handlebars so that she could hold on without hinging forward too far, and educated her about how riding without holding on places undue strain on her lower and middle back. We then had a lovely conversation about exercise intensity and pregnancy and... get this... heart rate monitoring. By the end of those 5 minutes, she really would not ONLY always hold onto the handlebar (my goal) -- but would be investing in a heart rate monitor, and thus investing in her health and that of her future child.

It was an important reminder on what can happen with a commitment to not giving up on people. It's tempting to detach, to focus one's energy on causes more likely to yield the greatest impact. But the likelihood of impact is also inextricably linked to one's belief in one's ability to have that impact. Like anything else, it's all in the way one talks to oneself.

As a Medical Student
On that note, I have recently started appreciating that I do NOT practice something at the crux of my coaching world throughout most of my medical world. And since, as described, they are the SAME world -- this discrepancy ends up being pretty unacceptable.

If there's one thing I talk/write/think about most in the world, it's the power of talking to one's self. The relationship between that practice and self-efficacy, the mediator between every aspect of intent and outcome, cannot be overstated. Truth be told, I talk to myself a lot. I tell myself how to think ("There is no reason to think you will fail this exam"), how to feel ("You are calm; you are confident.") -- even how to behave in order to achieve a certain desired thought or emotion ("If I ride my bike 50 miles right now, I will no longer be afraid of falling off my bike."). In the midst of adversity, I remind myself WHY I am weathering a particular challenge. I remind myself why anything matters, how it's going to feel when I've accomplished something (which is qualitatively different from "how it's going to feel if I DON'T accomplish something" as a motivator).

But sometimes I forget to do that, or do I do a poor job of it. When I'm anxious, panicky, reserved, or downright stupid in contexts where I don't feel in control, I am VERY mindful of those emotions and thoughts. I own them. But I could absolutely talk myseldf through them, just as I would on a bike -- the same way I do on an unending 30-minute hill at lactate threshold on a bike that absolutely SHOULD have blown off the road, or when I'm on a Spinner for 6 hours.

On that hill, do I EVER tell myself that I'm anxious and incompetent? No, I tell myself that I'm awesome.

Yet when someone asks me how medical school is, I tell them that I've gotten good at accepting that I don't know anything and that I'm useless in most contexts -- and that I'm ok with it. What the hell kind of premise is that for... ANYTHING?

Today, I shadowed two AWESOME pediatricians. When I met one of them, he asked me how first year went. And that's what I told him, which is what I tell everyone. It's the first thing that comes to mind, always -- it's scripted, by now. As soon as those words left my lips, though, this struck me as utterly ridiculous. Is that all that medical training is for me? No. And all that did was set a context for me to feel useless all day; and useless, I was. I learned a lot of specific, tangible pediatric content that I may or may not remember, and a lot of intangible stylistic skills that I most certainly will -- but by and large, I was useless.

But of what good does it do me to summarize today's experience that way? Would it not be more useful to say, "Hey, I learned to do x and y. I learned about z and a. And turns out, I really friggin' LIKE infants and toddlers, and I've solidified my intent to practice family medicine."

That's actually a huge deal -- yet in not talking to myself that way, I imprint the message that today was about being useless... not about making a majorly important, positive, exciting life decision.

Appreciating my limits is a huge and important part of my training, and will be for the rest of my life. But the greater point about this road thus far has been the continuous stream of opportunities to appreciate what I'm good at, what interests me, what I like, what I'd like to learn, what I can contribute now, what I will contribute next.

And just as I coach the folks I train, to give themselves permission to feel things, to make specific choices to meet their needs, to identify sub-sub-sub-goals on which to focus their improvement efforts, and to talk themselves through it all -- THAT'S how medical training needs to start being.

Starting right now. Because I told myself so.