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.


Lane said...

You talk to yourself? Really? Never would have guessed.

Melissa Marotta said...


Jennifer Sage said...

What a coach you are!
And what a doctor you will be!