Amidst 1600 people, I felt very alone. As I crossed the finish line of my third Century (100-mile) bike ride yesterday, passing a receiving line of cheerers calling and waving signs bearing 1599 other people's names, my eyes brimmed with tears. My stomach knotted with dread. Dread that this moment really was all there was going to be -- that whatever feeling I had in that moment -- call it pride, call it accomplishment, call it emptiness -- needed to be enough. I needed to be enough. I wasn't sure that I was.
As I stretched and iced my assorted musculoskeletal re-injuries on the shores of the Atlantic, I thought about what this sad, lonely, anticlimactic moment was supposed to teach me:
* Another step of discomfort-immersion?
* Practice in distinguishing between 'thoughts' and 'feelings,' and practice accepting the latter?
* Keeping me honest in appreciating that this part of my life (i.e., riding Centuries) that I associate with PURE internal validation really isn't completely devoid of external influences?
* Practice accepting that experiences can be powerful and influential in addressing some of my needs, without requirement to meet all my needs?
* Prompting me to re-evaluate and re-define my concept of "inadequacy" in a more realistic, compassionate way (i.e., if one can feel "inadequate" after riding 100 miles on a bike, one has an unfair definition of the word)?
* Practice accepting that my spectrum of "continuous, incremental improvement" does not require that every experience "n" is forever trumped by an "n+1?" Or that "improvement" doesn't always need to be measured on the usual scales (i.e., "faster than last time," "prouder than last time," "more joyous than last time") but can qualify as improvement all the same: "more insightful than last time," "more compassionate than last time."
And when I thought about that moment's potential utility -- for all of those reasons -- I felt less alone. More appreciative that, although this moment was drastically different from how it was "supposed" to be (or how I expected it to be), perhaps exactly as it needed to be.
This was supposed to be my first Century, an organized ride out of Hampton Beach, New Hampshire up and down the coast of New Hampshire and parts of Maine and Massachusetts. I'd rented a beachside suite for a weekend getaway with three friends -- they'd hang on the beach while I rode, meet me at the finish line, and then we'd all have the next day together. Two deviations, right off the bat:
1) This was no longer my first Century. I've done three, in an eight-week period: The first one was an accident. The second one was a pseudo-spontaneous desperate (and successful) act to conquer some unresolved anxiety.
2) My friends bailed, last minute.
So after taking my pulmonary exam on Friday, I set off for my solo adventure to Hampton Beach. I'd been up since 5AM after cramming til after midnight the night prior, so staying awake behind the wheel was a major, caffeine-fueled feat. I spent the drive thinking about why I was doing this. I wasn't excited. I was exhausted. I was driving to a random tourist trap to stay by myself in a random motel, and ride 100 miles for no reason. But was it really "for no reason?" No. At some point, this meant something to me -- so it was a matter of reminding myself what that was.
By the time I pulled onto the beach -- literally -- I had some idea. After a series of surprisingly calm navigation of confusing one-way streets, I dumped my gear off at the motel (a comfortable, AWESOME suite right on the water) and headed for the sand. It was 60 degrees but as sunny as could be -- and, yet, there were no human beings around. I had an entire beach front to myself. I walked barefoot back and forth for an hour, thinking about what I wanted out of what sure to be a very strange, very random trip.
This included my plans that night to read a book I'd borrowed from my roommate: "The Mindful Medical Student: "Staying Who You Are While Becoming Who You Want to Be" by the psychiatrist Jeremy Spiegel. Upon initial skimming, this seemed to be documentation from someone-who-legitimately-knows-what-he's-doing of precisely "what I do all day with my life to preserve sanity." He even has a chapter on synchronicities -- that is, finding and exploring connections between seemingly unrelated concepts (i.e., my whole friggin' life purpose) -- and describes it as an adaptive extension of pattern-recognition (i.e., a major skill for medical diagnosis). Validation. Nice.
I literally devoured this book from cover to cover the night before the ride. Dr. Spiegel's premise is that medical schools focus on technical content of medical education, while lacking training in the equally important skills and processes for self-reflection, exploring strengths and weaknesses, and coping with the uncertainty, ambiguity, and unease that are inherent to the practice of medicine leaving many a new doctor unable to navigate the challenges of their new world, and wrapped up in new identities that depart from their underlying character and values. I am fortunate that this will most certainly NOT be my problem. I've been preparing for this for years, even before medical school, because I anticipated this exact issue arising. I've been reading gazillions of physician and patient-written memoirs, thinking and writing a ton -- developing a whole arsenal of thoughts, and a structure for evaluating and balancing them over time. I'm also beyond fortunate that my program does include "life development" as a component of our curriculum. Though I appreciate that I am in a better place of self-awareness than this book's intended audience -- and I rejected some of the author's pseudo-over-the-top psychodynamic interpretations of self-evaluation (the fact that I can filter in selective sources of inspiration vs. filter out others is an important skill that I readily appreciated!), it was gratifying to read endorsements of what I do and think and write about to keep myself grounded in the moment, and document my evolving perspectives on which to look back over time. I link to previous posts on this blog, and my other blog, to keep myself honest. I'm comforted by my own consistency -- but the structure is built in to allow myself to process, evaluate, and "own" my changes, for good and for bad.
Amongst other themes he discusses (that perhaps I'll write about another time), Spiegel talks about undertaking "quasi-spiritual quests" to evaluate one's evolving identity. Do you recognize yourself? What's new, and do you like it? Where did it come from? How does a present conflict relate to conflicts of the past?
Ok, then. What's new? I was about to ride my 3rd 100-mile bike ride in an 8-week period. THAT'S new. Apparently, I have become someone who "does" Centuries. Just as my self-concept behind the wheel of a car evolved to that of a "Real Driver," I had begun to conceptualize myself as as "Real Cyclist." That's a big deal. Do I like it? Hells yes. Where did it come from? That's another story.
Most people in my life, including the people I train, don't understand why it's a big deal to me to ride 100 miles on a bike. It's not as crazy or "unrelatable" as it sounds. To me, riding my first Century represented a dramatic, epic triumph over an intimidating challenge that, while intellectually in-reach, was psychologically outside my comfort zone. But instead of comparable life challenges (i.e., becoming a competent physician), this was a challenge that I had COMPLETE control over conquering -- and for which my progress had measurable, objective feedback mechanisms: How much work could I do at 80% of lactate threshold (i.e., an intensity I can sustain literally all day long)? How much could I increase lactate threshold? How many beats could I lower my heart rate by altering my breath? Indisputable, objective feedback breeds confidence -- confidence that I could apply to the rest of my life. Confidence that I can and will do the things I say I'm going to do, no matter how intimidating. And confidence that came from training more intangible, immeasurable skills: language to coach myself through discomfort, awareness of the interplay between my breathing, form and movement, the ability to focus and husband all of my resources upon a specific sub-aspect of a task.
So after doing it once, why keep going? Because I could improve. I had complete control over improving my performance on this concrete task, unlike my perception of control over improvement in my medical training. I read and listen and ask questions with intent motivation to one day be qualified to care for human beings -- sometimes incoming stimuli stick; sometimes they don't. I can see and try an exam skill or procedure a gazillion times -- sometimes it sticks; sometimes it doesn't. I take and occasionally create opportunities to build confidence -- sometimes I succeed; sometimes I fail. My performance is unpredictable. Practice makes anxious.
As an athlete, my performance is measurable. I feel confident and strong and alive. On a bike, I can be the person I want to be and accomplish the things that mean something to me -- and in those moments, I genuinely believe that this translates to the rest of my world -- even if it doesn't. In those moments, my perception is all that matters. Contrary to public opinion, it is NOT difficult for me to please myself: in fact, some of my proudest, most memorable moments as an athlete were "mere" 30 minute periods of maintaining lactate threshold. Or there was another experience where I held 106% of lactate threshold for 10 minutes. 10 minutes! The woman who says she needs to ride 100 miles in order to feel "accomplished" cites a 10 minute experience amongst her proudest moments? Really? Yes.
The difference with a Century, though, is its potential to influence my self-concept as a Real Cyclist. I wanted that confidence so badly, and I worked for it. It's "epic" enough of an experience that I associate as unique to a Real Cyclist. Lots of real cyclists don't ride Centuries -- but if you ride a Century, you're absolutely a Real Cyclist. I keep riding these things to reinforce this new part of my identity that doesn't quite seem real enough to last-- almost like I'm afraid it will melt away.
One can't just up and ride 100 miles, though. It has to stand for something -- something that earns commitment, something that inspires some feeling that goes above and beyond the normal span of routine, daily emotions. Dramatic efforts call for dramatic reasons, reasons that mean something dramatic. And so, as I took on this third Century, I decided to dedicate it to the themes of this book that resonated with me most. As though to permanently weave them as strands of my character, to protect them from fraying or unraveling against the mangling challenges that are to be my life. Yes, I'm entitled to a little drama: I 'do' Centuries.
Finding Meaning in the Ordinary
Off the top of my head, I can list more than 20 profoundly meaningful examples of synchronicity -- but I'd sound psychotic. And it doesn't matter. I believe in every single one of them, and that perception of order and structure is comforting. The world makes sense when there are predictable patterns to pick out, an order to the universe. Medicine is that way -- and I never conceptualized any of this as "pattern recognition" as this book calls it. But as I prepared for this "ordinary" ride, I knew that it would have to mean something. Like anything, it was a matter of deciding what I wanted it to mean -- and, as it would turn out, appraising what it did mean... and appraising how the discrepancy between the two would affect me.
It's All in the Editing
Spiegel suggests conceptualizing medical school as an iMovie -- that instead of collecting all the fragments in contextless chronological order, that one can edit them in real time into a useful form that is easily revisited over time. Thus, this conscious creation represents an evolving, maturing personal and professional self. That totally resonated with me. That's what this blog is all about. I capture stories for a context -- but by and large, it's not about the facts. It's about their meanings. The meanings are what are going to stick -- the influences upon which I will want to look back on and remember their roots.
I thought about that as I rode, not only when I finished. As the breeze of the Atlantic tickled my ears and the sparkling waters interrupted my rhythmic, continuous breaths, I was mindful of actively blocking out everything else about that moment. My throbbing ankle, my kinked neck, my sore butt. I encoded the concept that, there I was, cruising along the Atlantic Ocean on a bicycle. And that right there in the moment, it was awesome.
An Arsenal of Comfort
Spiegel also writes about developing mechanisms for comforting yourself under stressful circumstances - stroking your own arm, telling yourself it's ok. I do a lot of that already. I've made it a point, over time, of developing an arsenal of tools to convince myself that I can endure a particular challenge (including, of course, accomplishing 100-mile rides). My latest tool comes from Century #2 -- the memory of the 85 mile mark (where I saw a road sign that told me it was 5 miles to Williston, a town 10 miles from home), when I bawled with intense pride and intrinsic reward that I would indeed triumph over my suffering and finish this overwhelming feat. At a few points since -- in "life," in training, and now here during this ride -- I told myself: "THIS is your Williston." Fascinatingly effective.
I also found myself acknowledging my discomfort with more natural compassion than usual. Usually, I have to force it when I'm riding: "Stop being so negative!" (i.e., reprimanding myself for reprimanding myself). "I'm tired. I hurt. I hate this." Ok. "I huuuuuuuuuuuurt." Ok. That's ok. If you want to stop, you can stop. "Hell no! I'm going to rock this. Go." More compassionate, and legitimately more successful outcome. This is just like I've been practicing in my medical training: acknowledging my discomfort, accepting it kindly, and keeping on.
"I'm Gonna Get Better At This, Too"
I "celebrated" my (lonely, isolated, sad) achievement with a 10 minute stretch on the beach and a peanut butter/banana/rice cake sandwich. Then I promptedly biked another mile to my car, not-so-discretely changed inside of it, and hit the road. I'd done what I came to do: now I could go home.
Cruising down the coastline, the cool saltiness breezing through my open windows, I smiled for the first time since crossing the finish line. As I pulled onto the Interstate, rockin' out to my empoweredly titled "REAL CYCLIST" mix with my shades on and my uber-scarred elbow out the window (another proud emblem of a "real cyclist," of course), the sunshine scorched my left cheek -- so strong that it bordered on discomfort. I drove on, though, and acclimated to the glow.
People say that the discomfort of medical training (i.e., anxiety, inadequacy, incompetency, loneliness) gets better over time, too. That the more you do, see and feel, that you develop skills, intuitions and competencies. Part of me accepts this as a logical reassurance; part of me thinks it's bullshit. A lot of me expects to never get good at certain tasks, no matter how many times I practice them. In moments of failure, success feels so far away -- so unattainable. And exposure to things I've not yet tried (i.e., no opportunity to fail) -- from emergency tracheotomies to routine IV insertion -- have bright red "this is NEVER going to be something you can do" warning sticker on their card catalog entry in my brain. But you know what? People said the same thing about driving and about biking -- and in those moments, those skills felt just as realistically impossible. But they happened, all the same. A year ago, I would never have CONCEIVED of any single occurence of the past 22 hours. A year ago, I barely knew how to drive; now, I drove 3 hours to create an epic, purposeful adventure for myself. A year ago, I barely knew how to ride a bike; now, I'd biked through 3 states for my third Century ride. I never expected basic competency, let alone comfort and confidence. For the first time in my life, I entertained the concept that medicine really would work the same way. If nothing else, my 22 hour adventure prompted me to appreciate that.
Uncertainty
When I arrived home, I mapped out the route I thought I'd taken (accounting for all my missed turns and accidental returns to civilization). I didn't remember 75% of the random turns I made but I included what I could. 80 miles. Could it be? Had I really not completed a full Century? I'd taken 7.5 hours (the others had taken me 8 hours, and were 107 and 105 miles respectively) -- but this was entirely flat (as opposed to the mountains of Central Vermont, which I climb slower), and I was obsessive about maintaining a faster cadence than usual on flats. Had all my stops asking random passersby for directions really taken up the length of time I'd have expected 20 miles to take me (1.25 hours)? It couldn't be -- no way. But then again, 20 miles is a huge gap to screw up on a map.
Discomfort over uncertainty has plagued me for most of my life. What will I be when I grow up? What college will I attend? Will I get a job? Will I spend the rest of my life with this person? Can I really pick up and move to the far-away land of Vermont and be ok? How's this all going to pan out? On one level, I've grown more comfortable with varying degrees of uncertainty. On another level, I simply have fewer uncertainties as I get older -- and, to some extent, avoid situations associated with long-term uncertainty.
So how fitting it is to take this concept of the Unachievable Achievement, which allegedly exists for all of these reasons/sub-achievements independent of the achievement itself (that may or may not be even more important than the achievement itself), and let history bear that I have complete uncertainty over whether or not I actually achieved it. Talk about playing the irony card. And if I didn't really ride 100 miles, which symbolized all these great things, do all of those other reasons/sub-achievements still hold?
That's why I wrote this post. After writing this, I cannot possibly answer that question with "no."
If I had a specific need to accomplish the concrete task of riding 100 miles, maybe I accomplished it; maybe I didn't. I don't console myself with assurance that I've legitimately ridden 100+ mile rides twice prior in the past eight weeks, or with the promise of re-attempting this feat. It's not about that. It's about whether THIS one "counted" -- whether it meant something, something that will apply to the rest of my world and really, truly have staying power.
But after all I've described... how could it not?
I took this on to triumph over doubt, to impose structure on inflooding chaos, to build confidence amidst anxiety. I did that, and then some. It's not the facts upon which I'll look back; it's the meanings.
Everything is in the editing. It's less lonely that way.
Sunday, September 27, 2009
Saturday, September 12, 2009
"Own Your Awkward" -- not to mention your inadequacy, your anxiety, and your utter dread.
My current self-improvement project over the past few weeks has been to immerse myself in experiences that optimize my anxiety, discomfort, and outright dread. As I described last week, I am endeavoring to train myself to mindfully "accept" negative emotions without attempting to control them. Active acknowledgment; passive acceptance.
He smiled.
While the experiences I've been structuring for myself this week may seem quite drastic in the moment, they're actually quite subtle. In the true spirit of Kaizen, it's been the little things: Asking a question after class of an intimidating lecturer. Volunteering to interpret an EKG in front of 114 people (knowing full well that I would fail and embarrass myself). Accepting a task of injecting a screaming, kicking infant with a vaccine. Giving medical advice to a guy with heart disease about the proper way to use his nitroglycerine when he has chest pain. Asking my preceptor if I could accompany him, yet again, to the hospital late at night.
What these opportunities have in common: 1) I've not wanted to do them -- more specifically, I've wanted to NOT do them; 2) I anticipated that they would trigger my oh-so-familiar catecholemine surge, and its predictable consquences of physiological discomfort; 3) I recognized that exposing myself to situations that predictably inspire panic, to teach myself that it's not the end of the world to be uncomfortable -- with the expectation that, one day, it might be comfortable to be uncomfortable.
At the hospital on Wednesday night, I could NOT have been more awkward. I stuttered. I walked into things. I stood behind the nursing station while my preceptor checked labs on the computer, staring at the ground wishing that I weren't there looking like a moron. Stop. Who cares that you look like a moron? Just stand there and look stupid. You're gaining SOMETHING in this moment just by being there. So just be there.
I followed my preceptor across the hall to see our first patient. The room was dark. Before me lay a 42 year old woman who has been in and out of the hospital for the past 4 YEARS with uncontrollable vomiting and abdominal pain. Her moans slowed to heavy breaths as she nodded to answer my preceptor's questions. As she spoke, my eyes glossed over with warm tears. I froze. What are you doing? I'm frozen. I'm tearful. I'm awkward. I'm uncomfortable. I can't do anything to alleviate this woman's discomfort, or my discomfort. I suck at life. No you don't. Your task isn't to do anything; it's to stand there. So stand there. Why are you uncomfortable? I've never seen anyone in this much physical distress before. This is what you're going to do for a living -- see people in physical distress and try to help them. Remember? Right. So I then attempted to scan my brain systematically for the potential causes of this woman's discomfort. What's in the abdomen? Uhhhh... Really? Can you really not retrieve the organs located in the abdominal cavity? Uhhhh...
It occurred to me that there are some things that I'm not going to be able to accept. I was somewhat ok with the concept that my brain didn't work while in the presence of a crying, moaning person in pain. I could, in theory, ultimately remove myself from that setting and think outside of her presence. But what I could NOT accept was how poorly I was communicating. I expected that I should be able to say SOMETHING -- ANYTHING. And I couldn't. As my preceptor left the room, I turned to follow him. The pit of uselessness in my stomach made me want to crawl into the corner and cry.
Say something. Anything.
"I'm sorry you're in so much pain..." I started.
She moaned.
She moaned.
"Please help me.... please help me.... can't someone help m..." she trailed off.
I placed my hand over her wrist. People tell me all the time about how touch is comforting. I didn't necessarily believe that my touch would do anything - but I figured it was worth a shot. Maybe it did, maybe it didn't.
"We're going to do everything we can to get to the bottom of what's causing your pain."
"Please help me.... please....."
"We're going to try to figure out what's causing this, and help you get better..."
"Please...."
I could tell quite immediately that we could continue this inadequate cycle all night, and that the meek touch of my hand on her wrist and my empty commitments to diligence weren't going to achieve a blessed thing. Still, I allowed the cycle to continue a few more rounds, then capped it off with another "I'm sorry" and a goodbye. I have never felt so inadequate.
I returned to the nursing station where my preceptor was documenting his exam. I looked down at the floor, saying nothing.
When we left a few hours later, I stopped him at the door.
"Do you have any thoughts on how to prevent your brain from shutting down when you get emotionally affected? I found that I was so distressed in the room with that patient that I literally couldn't retrieve the contents of the abdominal cavity."
He smiled.
"That's how I've spent my whole life..."
We then had a fantastic discussion about preventing the limbic system from interfering with other higher-level cognitive pathways (he used the expression "going limbic," which I adored) and about my project of immersion in uncomfortable, distressing situations. He shared that this is exactly how he approaches his world: identify a weakness, and immerse entirely until it goes away.
I write this 30 minutes from heading out on the greatest physical challenge of my life. I am riding my bike 50 miles to the house across the road from the clinic (where I stayed for the summer), staying over, and riding 105 miles tomorrow. Century #2 -- just because. Just because I 1) don't want to do it -- more specifically, I want to NOT do it; 2) I know full well that it will inspire terrible, terrible feelings of panic during certain instances (I'm clipping in with both feet for the first time; I'm riding terrain I've never seen before; I'm riding by myself through areas where there are no people for hours); 3) I see it as an opportunity to practice EXACTLY what I've been talking and thinking and writing about all this time.
In my coaching life, I talk/write so much about identifying goals -- and more importantly, the REASON for these goals. I stress the importance of investing time at the front end to develop very clear, specific psychological fuel. That's why I'm writing about this ride BEFORE I do it, instead of after.
In theory, there is no good reason to do this ride -- except for MY reason. I see this, symbolically, as something that is going to represent conquering something that is important to me. I could try to talk myself out of my discomfort. Or I could just BE uncomfortable -- and keep going anyway. And when I've done it, I will remember it for the rest of my life. Every time I stand at the foot of a patient's bed and can't do anything to help him or her. Every time I fear that I've made a fool of myself. Every time I think I'm inadequate or incompetent or weak.
Completing this challenge isn't going to make me smarter or smoother, or a better doctor. It's just a structure, and an important structure. Conquering this is giving me a framework to expose myself to what scares the hell out of me, accept my anxiety, and do it anyway -- thus demonstrating, once and for all, that challenges can be conquered INDEPENDENT of negative emotions.
I have resources around me to make this (mostly) safe. My roommate has offered to come get me from "wherever," and I have resources around the halfway point. I'm doing the first 50 miles (the part of the trip I've never seen before) in sneakers. I have tools and physical fuel. My psychological fuel, of course, is a genuine belief that I will have an entirely different life outlook when I conquer this. I'm excited to KNOW that I've done this. I'm excited to talk about it in the Spinning class I'm teaching tomorrow night about triumphing over adversity.
I'm excited to be in an uncomfortable situation and remind myself that I did this, for the reasons that I did this.
I'm excited to be in an uncomfortable situation and remind myself that I did this, for the reasons that I did this.
So now, the only thing left is to DO this.
EDIT 9/13/09 4:10PM: I DID this. It was the most painful journey imaginable. But also the proudest.
EDIT 9/13/09 4:10PM: I DID this. It was the most painful journey imaginable. But also the proudest.
Thursday, September 3, 2009
The "Shoulds" and "Should Nots" of Awkwardness.
It might be said that my protocol for interacting with my environment is a tad rigid.
Perceive stimulus --> evaluate stimulus --> decide how stimulus "should" be --> rationalize/negotiate/strategize cognitive construct to make stimulus match intention. Translated as: "Reality is the way I say it is."
Most of the time, this serves me well. I decided I "should" be able to ride 100 miles on my bike -- so I rode 107 (just a few miles shy of the Canadian border) and am primed to ride 110 in 3 weeks. I decided I "should" be able to do a study on an obscure concept about which nobody admits to thinking about except me (even though it changes lives, and the potential to be applied to EVERYTHING), so I launched a survey that collected 230 responses from around the world. I decided I "should" be able to leg-press twice my body weight -- and, as of a week ago, I can. I decided I "should" be training at my fantasy clinic that I discovered in an obscure magazine article before I even interviewed for medical school -- so I, well, am. I decided I "should" spend tonight writing about my psychological strife instead of studying, despite having also spent the past 2 hours coaching people on a bike. Reality is the way I say it is, after all.
Yet. when I decide that I "should" be able to get through stressful life experiences without anxiety or any negative emotions -- any emotions at all, even -- this intention is not only unsuccessful but it's absurd. When I experience a response that departs from my intention, I expend a TON of energy to shut it down and control it -- forcing reality, in some way, to be as malleable as it is in 90% of my life circumstances.
So for the last few weeks, I've been trying to drop the word "should" from my vocabulary. As adaptive as it has been for some of the examples I've cited, its destructiveness has been way more profound. I "should" be useful at all times at the clinic, so as not to be perceived as a mooch off their energy and resources. I "should" feel more comfortable performing every single clinical examination I know about. I "should" sleep more, study more. Consternate less.
Instead, I've been making an effort to "accept" reality as it is -- not in spite of my intentions exactly; just independent of them. I'm not very good at this process. I "accept" that part, at least.
Last night, I was at the clinic really late seeing patients with my preceptor. Around 10PM, he announced that he had to go admit one of his patients to the hospital through the ED. I asked if I could accompany him. (See: creating opportunities). I told him that I had no legit hospital experience and that it made me anxious, and that I "should" get over this by exposing myself to it. He supported this plan. I think he's amused by my ready professions of what makes me anxious and what I intend to do about it. I think he's also quite perceptive about what makes me anxious. When I don't have a useful structure with which to organize incoming stimuli and/or I lack confidence about my abilities or decisions, these patterns quite predictably set me off. So he spent a half hour teaching me how to organize a hospital admissions note. He's so awesome.
So, 11:30PM. EVERYTHING about my arrival was awkward. It took me 5 attempts to park straight. I caught my stethescope in my car door. Upon entering the ED, I felt the wave of "awkward, useless, why am I here?!" wash over me. Yes, that wave. I timidly avoided interacting with human beings until my preceptor introduced me, lest I be faulted for draining attentional or oxygen resources me.
'I "should" not feel this way,' I thought. This is a great opportunity, and you are ruining it by being ridiculous. Stop it.
Then I remembered Operation: Acceptance.
Yes, I am anxious. Yes, I am awkward. It's ok to be awkward. This is the first time you're in this situation. You're fine.
My preceptor pulled up a CT scan of the patient we were here to see. 72 year old man with Stage 4 esophageal cancer -- which even a 2nd-year medical student knows is a really dismal thing. Though I often can't tell a heart from an intestine on CT, I knew exactly what I was looking at -- and it was bad. His esophagus had become completely obstructed by the tumor. Part of me felt confident that I knew what I was seeing; part of me felt guilty for possessing this knowledge.
We went in to see the patient. His frail, bony legs stuck out beneath his hospital gown. His sunken face looked up with indifference. "I can't keep food down, Doc. It comes right up."
That was the "real life" translation of what I had just seen on the computer screen. It aligned perfectly. I stood there, possessing knowledge that explained this man's world -- defined it, scripted it towards an ending that I could anticipate far more clearly than he could.
I gave myself permission to freeze and mindfully observe how I felt about this moment, a preview of so many moments just like it that are to come. Observing each sensation, without interpreting it. I was awkward and useless -- and whether that "should" have been or not was irrelevant. I was training to be right there in that moment -- that heavy, painful moment -- accepting every aspect of my reality.
And in that moment, reality was ok.
Perceive stimulus --> evaluate stimulus --> decide how stimulus "should" be --> rationalize/negotiate/strategize cognitive construct to make stimulus match intention. Translated as: "Reality is the way I say it is."
Most of the time, this serves me well. I decided I "should" be able to ride 100 miles on my bike -- so I rode 107 (just a few miles shy of the Canadian border) and am primed to ride 110 in 3 weeks. I decided I "should" be able to do a study on an obscure concept about which nobody admits to thinking about except me (even though it changes lives, and the potential to be applied to EVERYTHING), so I launched a survey that collected 230 responses from around the world. I decided I "should" be able to leg-press twice my body weight -- and, as of a week ago, I can. I decided I "should" be training at my fantasy clinic that I discovered in an obscure magazine article before I even interviewed for medical school -- so I, well, am. I decided I "should" spend tonight writing about my psychological strife instead of studying, despite having also spent the past 2 hours coaching people on a bike. Reality is the way I say it is, after all.
Yet. when I decide that I "should" be able to get through stressful life experiences without anxiety or any negative emotions -- any emotions at all, even -- this intention is not only unsuccessful but it's absurd. When I experience a response that departs from my intention, I expend a TON of energy to shut it down and control it -- forcing reality, in some way, to be as malleable as it is in 90% of my life circumstances.
So for the last few weeks, I've been trying to drop the word "should" from my vocabulary. As adaptive as it has been for some of the examples I've cited, its destructiveness has been way more profound. I "should" be useful at all times at the clinic, so as not to be perceived as a mooch off their energy and resources. I "should" feel more comfortable performing every single clinical examination I know about. I "should" sleep more, study more. Consternate less.
Instead, I've been making an effort to "accept" reality as it is -- not in spite of my intentions exactly; just independent of them. I'm not very good at this process. I "accept" that part, at least.
Last night, I was at the clinic really late seeing patients with my preceptor. Around 10PM, he announced that he had to go admit one of his patients to the hospital through the ED. I asked if I could accompany him. (See: creating opportunities). I told him that I had no legit hospital experience and that it made me anxious, and that I "should" get over this by exposing myself to it. He supported this plan. I think he's amused by my ready professions of what makes me anxious and what I intend to do about it. I think he's also quite perceptive about what makes me anxious. When I don't have a useful structure with which to organize incoming stimuli and/or I lack confidence about my abilities or decisions, these patterns quite predictably set me off. So he spent a half hour teaching me how to organize a hospital admissions note. He's so awesome.
So, 11:30PM. EVERYTHING about my arrival was awkward. It took me 5 attempts to park straight. I caught my stethescope in my car door. Upon entering the ED, I felt the wave of "awkward, useless, why am I here?!" wash over me. Yes, that wave. I timidly avoided interacting with human beings until my preceptor introduced me, lest I be faulted for draining attentional or oxygen resources me.
'I "should" not feel this way,' I thought. This is a great opportunity, and you are ruining it by being ridiculous. Stop it.
Then I remembered Operation: Acceptance.
Yes, I am anxious. Yes, I am awkward. It's ok to be awkward. This is the first time you're in this situation. You're fine.
My preceptor pulled up a CT scan of the patient we were here to see. 72 year old man with Stage 4 esophageal cancer -- which even a 2nd-year medical student knows is a really dismal thing. Though I often can't tell a heart from an intestine on CT, I knew exactly what I was looking at -- and it was bad. His esophagus had become completely obstructed by the tumor. Part of me felt confident that I knew what I was seeing; part of me felt guilty for possessing this knowledge.
We went in to see the patient. His frail, bony legs stuck out beneath his hospital gown. His sunken face looked up with indifference. "I can't keep food down, Doc. It comes right up."
That was the "real life" translation of what I had just seen on the computer screen. It aligned perfectly. I stood there, possessing knowledge that explained this man's world -- defined it, scripted it towards an ending that I could anticipate far more clearly than he could.
I gave myself permission to freeze and mindfully observe how I felt about this moment, a preview of so many moments just like it that are to come. Observing each sensation, without interpreting it. I was awkward and useless -- and whether that "should" have been or not was irrelevant. I was training to be right there in that moment -- that heavy, painful moment -- accepting every aspect of my reality.
And in that moment, reality was ok.
Wednesday, August 5, 2009
Power & Privilege
Drip. The septocaine dripped pristinely from my needle as it approached her shiny, pink flesh. I caught the drop with my gloved finger, then tightened my grip on the steel ring. Pulling back the patient's cheek pinched between my two fingers, I squinted one eye to verify the alignment of the most lethal thing I've ever held in my hand with the pterygomandibular raphe between her gum and her bone. Breathe. PLUNGE. Holy shit. I just injected a human being's jaw.
Yesterday, I injected a toe. The idea of sticking a needle into a human being -- having them trust you to literally seize control of a body part and insert a sharp object, introducing a dangerous substance into said body part -- is, on its face, absurd. Not as absurd as taking a pair of forceps, gripping a toenail, and peeling it off like an orange peel. But I did that, too. This somehow became my life.
Later in the day, I observed one of the PAs perform a physical exam on an adolescent girl. I contributed little; I was content to stand in the corner and observe a series of awkward interactions and then return to my regular scheduled programming of color-coded Excel spreadsheets. Suddenly, a voice interjected itself into my concentration.
"Sparky!" called a nurse (yes, that's what they call me at the clinic; and, yes, I answer to it). "Do you want me to do a vision test?"
"Huh?"
"A vision test. Like, with the eye chart. Do you want to order that for the patient you just saw?"
Order a test? Like, without consulting with someone else who's licensed to practice medicine or remotely knows what he or she is talking about? Am I even qualified to make this decision? No. Definitely not qualified. Wait. It's a vision test. Duh. You can totally decide to do a vision test. Why wouldn't you do a vision test? Why is this person even asking me? Oh shit. Because I'm a medical student; I'm a stand-in for a representative of medical decision-makers.
"Uh, sure, go ahead. Why not?"
"Ok, Sparky! Right away!"
WHAT?! Did that just happen? Yes, it did. And welcome to reality. This is how it's going to be: someone who knows a shit ton more than you about, well, EVERYTHING (i.e., a nurse) is going to look to default to your judgment just because you are en route to one day to a prescribed position of hierarchy. On its face, absurd -- just like peeling off a toenail. But this, too, somehow became my life.
I continue to spend a lot of time reflecting on the profound privilege, honor, and absurdity that is being trusted by people without expending any effort to earn it, apart from putting on a white coat. I didn't earn the trust of the two men who let me examine their testicles today. Or the woman who let me witness the unveiling of her painful, gnarly atrophic vaginitis. Or the guy who let me insert a lubed, gloved finger in his rectum. No, I did not earn any of that.
When it happens, I am always grateful. I thank people for their generosity in contributing to my education and development: I look them in the eye and tell them how much I appreciate the opportunity they afford me -- how I'm always so surprised at how generous people are, how I can never believe that anyone lets me do or see or learn half what I do all day. I rant and rave because a) these folks deserve to be thanked, and b) it's almost an act of earning trust/confidence in reverse order -- as in "See? I'm a good person! You let me do this absurd thing, and look how good a person I am -- you should feel great about your decision to let me do this absurd thing." In the end, it's the only effort I expend to earn their impression of me. I earn the warm and fuzzy smile I get next.
Today, a patient consented to let me observe the interview portion of her visit with a PA but not the exam. Totally understandable. I stood in the corner and tried to stay out of the way. I fixed my eyes on the woman, her pearl necklace and earrings in jarring contrast to her examination gown. In jarring contrast to her elegance, to her pride. I listened thoughtfully with my eyes. I smiled and nodded at appropriate intervals. She snuck sideways peeks at me.
"So when you said that you've had these symptoms for th..."
"Wait. When we get to the exam, she can stay," the patient interrupted. "I feel comfortable with her... you... now." She turned towards me and smiled.
It was a routine physical exam, with a routine pap smear. But it was one of the most memorable visits I've had the privilege to observe -- because I actually felt like I EARNED the opportunity to be there. When I thanked her afterwards, my words gushed with effusive gratitude.
"You're going to be a great doctor," she said.
I touched her shoulder on the way out of the room, knowing that this moment would touch my life forever.
Armed by this dose of validation and confidence later in the evening, I grabbed the chart of a patient who came to see my preceptor for a cough. Great. An acute problem. I am TOTALLY qualified to go in and take a history and do examinations of organ systems I've actually formally learn how to examine. Then I can come out and present to my preceptor and feel really great about myself. Yes. Good plan. Let's go.
I took a history, did a few basic exams, wrote up a pretty good note. Pseudo-awkward guy, a bit unfocused -- yet I found that I was able to reel him in, inject structure and chronology into his account, and connect with him about the context of his life. He's a cyclist: that was my hook. Just as I was about to go present the patient's case to my preceptor, he shot off a bunch of questions about the heart. What steps could he take to reduce his risk of heart disease? I totally could handle that but wanted to do it in the presence of my preceptor, so I validated his exercise habits and said that we'd talk about this more during the visit. Then he asked something about surveillance ultrasonography -- which I somehow, in that moment, felt more qualified to speak on. What?! So there I was, fielding his question which I have NO idea why on earth I felt comfortable fielding. Sure, I fielded it ambiguously and said we'd talk about it during the visit -- but responded with far greater detail than the diet/exercise (i.e., the things I know most about in the world) question. I gave him stuff to latch onto, stuff that overshadowed my "yeahhhhh, I'm just a medical student" disclaimer.
I left the room and presented the case to my preceptor, who praised me for my workup. Again, felt on top of the world.
We go back in, come up with a plan, wrap up the acute issue -- then I prompt the patient to raise his "heart questions." When he asks about cardiac risk prevention, I launch into an extensive discussion about fish oil, exercise, blah blah blah. Wonderful. Then he raises the ultrasonography question, and my preceptor's eyes widened. "Actually, there is no relationship between [insert EVERYTHING I said to this guy]." He continues by citing studies and important international bodies' positions on his question, distracting him from the fact that [insert EVERYTHING I said to this guy] was totally and utterly wrong.
Gulp. Breathe. Tongue on the roof of teeth, inhale (my new favorite trick, taught to me by my friend Shefali, to enforce diaphragmatic breaths). Exhale long. Breathing my heart rate down. It's ok. You didn't ruin anyone's life. You're allowed to sound like an idiot. Nobody expects you to NOT be an idiot. It's ok. Breathe.
Downside of the privilege of being trusted: Every word out of your mouth counts. If you don't have confidence in the words that leave your mouth, do not guess. If you think you know of a concept that is peripherally related to another concept, do not link them unless you have specifically seen them directly linked. I was mortified.
After my preceptor left, I apologized to the patient for misspeaking and thanked him for the prompt to learn something along with him. He told me it was no big deal. I then spent 30 minutes providing dietary consultation (we had referred him to a dietitian, and I doubted that he would ever go). I felt like I redeemed myself and re-earned the trust that I'd enjoyed before I decided I was a sonography expert.
I waited around an hour before my preceptor finished up with his last patient, so that I could apologize to him and assure him how careful I would be in the future. So that I could thank him for not embarrassing me in front of the patient, for finding a way to correct me without undermining my confidence.
He surfaced: "We need to talk."
Oh shit. This was worse than I thought. My whole relationship with this clinic was over. They trusted a first-year medical student to interact independently with their patients, and now look what happened. I failed. I disappointed them. I suck. How did I do that?! Why did I do that?!
I followed him to his office.
"I am so sorry..." I began.
"For what?"
"For misspeaking about the ultrasound. For disappointing you."
He laughed.
"That was so not a big deal. Come on, let's go meet about your project."
Crisis averted; lesson learned. Being trusted to answer a patient's question is the equivalent of being trusted to inject a potent, potentially lethal anesthetic into a patient's jaw. It requires just as much preparation and precision, assuming just as many risks. And when you do it right, just as many rewards.
Yesterday, I injected a toe. The idea of sticking a needle into a human being -- having them trust you to literally seize control of a body part and insert a sharp object, introducing a dangerous substance into said body part -- is, on its face, absurd. Not as absurd as taking a pair of forceps, gripping a toenail, and peeling it off like an orange peel. But I did that, too. This somehow became my life.
Later in the day, I observed one of the PAs perform a physical exam on an adolescent girl. I contributed little; I was content to stand in the corner and observe a series of awkward interactions and then return to my regular scheduled programming of color-coded Excel spreadsheets. Suddenly, a voice interjected itself into my concentration.
"Sparky!" called a nurse (yes, that's what they call me at the clinic; and, yes, I answer to it). "Do you want me to do a vision test?"
"Huh?"
"A vision test. Like, with the eye chart. Do you want to order that for the patient you just saw?"
Order a test? Like, without consulting with someone else who's licensed to practice medicine or remotely knows what he or she is talking about? Am I even qualified to make this decision? No. Definitely not qualified. Wait. It's a vision test. Duh. You can totally decide to do a vision test. Why wouldn't you do a vision test? Why is this person even asking me? Oh shit. Because I'm a medical student; I'm a stand-in for a representative of medical decision-makers.
"Uh, sure, go ahead. Why not?"
"Ok, Sparky! Right away!"
WHAT?! Did that just happen? Yes, it did. And welcome to reality. This is how it's going to be: someone who knows a shit ton more than you about, well, EVERYTHING (i.e., a nurse) is going to look to default to your judgment just because you are en route to one day to a prescribed position of hierarchy. On its face, absurd -- just like peeling off a toenail. But this, too, somehow became my life.
I continue to spend a lot of time reflecting on the profound privilege, honor, and absurdity that is being trusted by people without expending any effort to earn it, apart from putting on a white coat. I didn't earn the trust of the two men who let me examine their testicles today. Or the woman who let me witness the unveiling of her painful, gnarly atrophic vaginitis. Or the guy who let me insert a lubed, gloved finger in his rectum. No, I did not earn any of that.
When it happens, I am always grateful. I thank people for their generosity in contributing to my education and development: I look them in the eye and tell them how much I appreciate the opportunity they afford me -- how I'm always so surprised at how generous people are, how I can never believe that anyone lets me do or see or learn half what I do all day. I rant and rave because a) these folks deserve to be thanked, and b) it's almost an act of earning trust/confidence in reverse order -- as in "See? I'm a good person! You let me do this absurd thing, and look how good a person I am -- you should feel great about your decision to let me do this absurd thing." In the end, it's the only effort I expend to earn their impression of me. I earn the warm and fuzzy smile I get next.
Today, a patient consented to let me observe the interview portion of her visit with a PA but not the exam. Totally understandable. I stood in the corner and tried to stay out of the way. I fixed my eyes on the woman, her pearl necklace and earrings in jarring contrast to her examination gown. In jarring contrast to her elegance, to her pride. I listened thoughtfully with my eyes. I smiled and nodded at appropriate intervals. She snuck sideways peeks at me.
"So when you said that you've had these symptoms for th..."
"Wait. When we get to the exam, she can stay," the patient interrupted. "I feel comfortable with her... you... now." She turned towards me and smiled.
It was a routine physical exam, with a routine pap smear. But it was one of the most memorable visits I've had the privilege to observe -- because I actually felt like I EARNED the opportunity to be there. When I thanked her afterwards, my words gushed with effusive gratitude.
"You're going to be a great doctor," she said.
I touched her shoulder on the way out of the room, knowing that this moment would touch my life forever.
Armed by this dose of validation and confidence later in the evening, I grabbed the chart of a patient who came to see my preceptor for a cough. Great. An acute problem. I am TOTALLY qualified to go in and take a history and do examinations of organ systems I've actually formally learn how to examine. Then I can come out and present to my preceptor and feel really great about myself. Yes. Good plan. Let's go.
I took a history, did a few basic exams, wrote up a pretty good note. Pseudo-awkward guy, a bit unfocused -- yet I found that I was able to reel him in, inject structure and chronology into his account, and connect with him about the context of his life. He's a cyclist: that was my hook. Just as I was about to go present the patient's case to my preceptor, he shot off a bunch of questions about the heart. What steps could he take to reduce his risk of heart disease? I totally could handle that but wanted to do it in the presence of my preceptor, so I validated his exercise habits and said that we'd talk about this more during the visit. Then he asked something about surveillance ultrasonography -- which I somehow, in that moment, felt more qualified to speak on. What?! So there I was, fielding his question which I have NO idea why on earth I felt comfortable fielding. Sure, I fielded it ambiguously and said we'd talk about it during the visit -- but responded with far greater detail than the diet/exercise (i.e., the things I know most about in the world) question. I gave him stuff to latch onto, stuff that overshadowed my "yeahhhhh, I'm just a medical student" disclaimer.
I left the room and presented the case to my preceptor, who praised me for my workup. Again, felt on top of the world.
We go back in, come up with a plan, wrap up the acute issue -- then I prompt the patient to raise his "heart questions." When he asks about cardiac risk prevention, I launch into an extensive discussion about fish oil, exercise, blah blah blah. Wonderful. Then he raises the ultrasonography question, and my preceptor's eyes widened. "Actually, there is no relationship between [insert EVERYTHING I said to this guy]." He continues by citing studies and important international bodies' positions on his question, distracting him from the fact that [insert EVERYTHING I said to this guy] was totally and utterly wrong.
Gulp. Breathe. Tongue on the roof of teeth, inhale (my new favorite trick, taught to me by my friend Shefali, to enforce diaphragmatic breaths). Exhale long. Breathing my heart rate down. It's ok. You didn't ruin anyone's life. You're allowed to sound like an idiot. Nobody expects you to NOT be an idiot. It's ok. Breathe.
Downside of the privilege of being trusted: Every word out of your mouth counts. If you don't have confidence in the words that leave your mouth, do not guess. If you think you know of a concept that is peripherally related to another concept, do not link them unless you have specifically seen them directly linked. I was mortified.
After my preceptor left, I apologized to the patient for misspeaking and thanked him for the prompt to learn something along with him. He told me it was no big deal. I then spent 30 minutes providing dietary consultation (we had referred him to a dietitian, and I doubted that he would ever go). I felt like I redeemed myself and re-earned the trust that I'd enjoyed before I decided I was a sonography expert.
I waited around an hour before my preceptor finished up with his last patient, so that I could apologize to him and assure him how careful I would be in the future. So that I could thank him for not embarrassing me in front of the patient, for finding a way to correct me without undermining my confidence.
He surfaced: "We need to talk."
Oh shit. This was worse than I thought. My whole relationship with this clinic was over. They trusted a first-year medical student to interact independently with their patients, and now look what happened. I failed. I disappointed them. I suck. How did I do that?! Why did I do that?!
I followed him to his office.
"I am so sorry..." I began.
"For what?"
"For misspeaking about the ultrasound. For disappointing you."
He laughed.
"That was so not a big deal. Come on, let's go meet about your project."
Crisis averted; lesson learned. Being trusted to answer a patient's question is the equivalent of being trusted to inject a potent, potentially lethal anesthetic into a patient's jaw. It requires just as much preparation and precision, assuming just as many risks. And when you do it right, just as many rewards.
Monday, August 3, 2009
One Year Later.
Saturday was the one year anniversary (or, as my friend Nicole calls it: "Vermontiversary") of my most epic life upgrade to date. One year ago, I began -- quite literally -- an entire new life. I shed my boyfriend of two years, 85% of my hair, my access to 24/7 Internet takeout, and completely and utterly started over.
I learned to drive. I learned to compost. I learned to be still, and breathe, and trust myself. I learned how it feels to carve out a world entirely of my own making.
My departure was not without drama. Taking a break from loading up the moving van for a Diet Dr. Pepper at the Duane Reade across the street from my home of 4.5 years, my first cold swig triggered an episode of vasovagal syncope. I blacked out and hit the tile floor HARD, losing consciousness for several minutes. An elderly woman waited with me for an hour until my father could come take me to the hospital; turns out, she was my next-door neighbor. We'd never met before -- how New York. Just as I would be tempted to bid my city adieu with the taste of coldness, isolation and detachment I'd come to develop in my mouth over time, here I was being reminded that there really was a sense of 'community' -- even if it were masked 99% of the time by exhaust fumes, deafening horns, and swearing cabbies. Symbolically, I was prompted to take an entirely different farewell snapshot to New York than I was prepared to stage.
My experience at the Emergency Department was symbolic in its own right. In three hours' time, I experienced EVERYTHING possible that I would never, ever, EVER do to a human being. I was made to sit exposed in the waiting room in a patient gown. I was left completely topless for 20 minutes behind a half-open curtain waiting for an EKG. I was put into a bed soaked in someone else's urine. I was passed along a string of strangers, none of whom introduced themselves or even asked me how I was feeling. I was ignored by more than a dozen residents, nurses and techs evading eye contact as I bawled on a stretcher in a desolate corridor. I was dismissed and discouraged by the physician entrusted with my life. I was scared and alone and helpless, struggling to navigate the unknown amidst a hostile sea of strangers. There, literally "on the way to medical school," I had one of the most powerful training experiences I will ever have. Thank you, New York University, for contributing to my education. You'd better believe that this, too, was a snapshot moment.
What's in the snapshot I take today, one year later?
Here I am, on the screened-in porch of a rural Vermont cottage up a dirt road. I'm training at the clinic of my dreams, at the side of some of the most inspirational characters I could ever have invented to contribute to my development as a physician. I have a ridiculously elaborate new set of neural circuits that contain hundreds of thousands of new words and concepts and patterns, some of which have already contributed to human beings' lives. I've built a utopian coaching world here, where I can "do my thing" uninhibitedly. I've successfully acted on some pretty daring, quirky ideas: mindfulness trainings on a Spinner, an Intro to HR Training course, a legit scientific inquiry into the psychology of HR training (16 responses away from the finish line...). I'm 6 weeks away from my first 100 mile bike ride. I've invested in myself and in the things I've decided I want. Nice shot, indeed.
Last week, my preceptor returned to the clinic. I was ecstatic. Over the course of eight weeks, we've only been in town at the same time for maybe eight days -- he's been traveling a lot, which is disappointing because he's my absolute favorite person to train under. Everyone else teaches me well, extends me opportunities to practice various tangible and intangible skills, etc. But this guy is the only one who really directly empowers me to flex my 'usefulness muscles.' He lets me educate patients about diet and exercise (even heart rate training!) with great specificity. I'm not merely "filling in holes" -- for those particular moments, I perceive that I am genuinely contributing some specific added value. He knows that confidence is everything, and he takes it very seriously as his duty as my mentor to build my confidence through experiences he knows that I a) really enjoy and b) at which I am decent at worst, if not occasionally pretty good. I really only know 1% of useful medical concepts -- but he has a way of teaching me in a way that doesn't force me to frame it as such. "You remember that..." (when it's an entirely brand new concept). He describes his thought process to me on the fly ("I saw this, and thought that - so I tried this, and it worked/didn't work, so I knew this..."), which is a format I totally adore and am now making a 'note to self' to express my appreciation for that aspect of his style, as I work to develop my own thinking style. It's collaborative and gentle, and just WORKS. It's like that poster in the UVM library I reference a lot: "Knowledge is the ability to make the people around you feel smart." This guy is brilliant.
Upon his return, he took me out for a quick bite to eat during a gap in the night clinic schedule. "So you've got a week left," he started. "What do you want to learn? What can I do to contribute to your experience? What do you want more experience doing?"
Rewind back to the day I met him, in February.
"What do you want to do with your summer?" he asked me, then. For all intents and purposes, he was asking me what I wanted to do with my life.
And I didn't know. I didn't know anything, and thus I wanted to see and do and experience EVERYTHING. To the end that I couldn't specifically request ANYTHING. I was limited by my lack of limits.
If this summer has been about nothing at all, it's been learning to appreciate that it's OK to ask for what I want. And, without expending much effort to ponder this, the "what I want" part has presented itself on its own. Now I could answer the question, without hesitation.
I told him what I wanted. I told him I lacked confidence in working with my hands, and in describing my findings. I told him I wanted experience presenting patient histories and findings to him.
"Done," he said. "We'll do that."
And that night, we did. Right away, BAM. I got exactly what I asked for, just like that.
I didn't always know what I was doing or seeing, and I wasn't always useful. But I was confident enough to ask for clarification or elaboration when something didn't feel fluid. That confidence had absolutely nothing to do with my abilities or some sort of "natural progression" of events; it had everything to do with the deliberate, specific efforts of my mentor to contribute to the deliberate, specific experience I had expressed that I was seeking.
Knowledge is the ability to make the people around you feel smart, after all. One year later, the characters, the experiences, and the opportunities that mark my new life continue to remind me that this move was the smartest thing I've ever done.
I learned to drive. I learned to compost. I learned to be still, and breathe, and trust myself. I learned how it feels to carve out a world entirely of my own making.
My departure was not without drama. Taking a break from loading up the moving van for a Diet Dr. Pepper at the Duane Reade across the street from my home of 4.5 years, my first cold swig triggered an episode of vasovagal syncope. I blacked out and hit the tile floor HARD, losing consciousness for several minutes. An elderly woman waited with me for an hour until my father could come take me to the hospital; turns out, she was my next-door neighbor. We'd never met before -- how New York. Just as I would be tempted to bid my city adieu with the taste of coldness, isolation and detachment I'd come to develop in my mouth over time, here I was being reminded that there really was a sense of 'community' -- even if it were masked 99% of the time by exhaust fumes, deafening horns, and swearing cabbies. Symbolically, I was prompted to take an entirely different farewell snapshot to New York than I was prepared to stage.
My experience at the Emergency Department was symbolic in its own right. In three hours' time, I experienced EVERYTHING possible that I would never, ever, EVER do to a human being. I was made to sit exposed in the waiting room in a patient gown. I was left completely topless for 20 minutes behind a half-open curtain waiting for an EKG. I was put into a bed soaked in someone else's urine. I was passed along a string of strangers, none of whom introduced themselves or even asked me how I was feeling. I was ignored by more than a dozen residents, nurses and techs evading eye contact as I bawled on a stretcher in a desolate corridor. I was dismissed and discouraged by the physician entrusted with my life. I was scared and alone and helpless, struggling to navigate the unknown amidst a hostile sea of strangers. There, literally "on the way to medical school," I had one of the most powerful training experiences I will ever have. Thank you, New York University, for contributing to my education. You'd better believe that this, too, was a snapshot moment.
What's in the snapshot I take today, one year later?
Here I am, on the screened-in porch of a rural Vermont cottage up a dirt road. I'm training at the clinic of my dreams, at the side of some of the most inspirational characters I could ever have invented to contribute to my development as a physician. I have a ridiculously elaborate new set of neural circuits that contain hundreds of thousands of new words and concepts and patterns, some of which have already contributed to human beings' lives. I've built a utopian coaching world here, where I can "do my thing" uninhibitedly. I've successfully acted on some pretty daring, quirky ideas: mindfulness trainings on a Spinner, an Intro to HR Training course, a legit scientific inquiry into the psychology of HR training (16 responses away from the finish line...). I'm 6 weeks away from my first 100 mile bike ride. I've invested in myself and in the things I've decided I want. Nice shot, indeed.
Last week, my preceptor returned to the clinic. I was ecstatic. Over the course of eight weeks, we've only been in town at the same time for maybe eight days -- he's been traveling a lot, which is disappointing because he's my absolute favorite person to train under. Everyone else teaches me well, extends me opportunities to practice various tangible and intangible skills, etc. But this guy is the only one who really directly empowers me to flex my 'usefulness muscles.' He lets me educate patients about diet and exercise (even heart rate training!) with great specificity. I'm not merely "filling in holes" -- for those particular moments, I perceive that I am genuinely contributing some specific added value. He knows that confidence is everything, and he takes it very seriously as his duty as my mentor to build my confidence through experiences he knows that I a) really enjoy and b) at which I am decent at worst, if not occasionally pretty good. I really only know 1% of useful medical concepts -- but he has a way of teaching me in a way that doesn't force me to frame it as such. "You remember that..." (when it's an entirely brand new concept). He describes his thought process to me on the fly ("I saw this, and thought that - so I tried this, and it worked/didn't work, so I knew this..."), which is a format I totally adore and am now making a 'note to self' to express my appreciation for that aspect of his style, as I work to develop my own thinking style. It's collaborative and gentle, and just WORKS. It's like that poster in the UVM library I reference a lot: "Knowledge is the ability to make the people around you feel smart." This guy is brilliant.
Upon his return, he took me out for a quick bite to eat during a gap in the night clinic schedule. "So you've got a week left," he started. "What do you want to learn? What can I do to contribute to your experience? What do you want more experience doing?"
Rewind back to the day I met him, in February.
"What do you want to do with your summer?" he asked me, then. For all intents and purposes, he was asking me what I wanted to do with my life.
And I didn't know. I didn't know anything, and thus I wanted to see and do and experience EVERYTHING. To the end that I couldn't specifically request ANYTHING. I was limited by my lack of limits.
If this summer has been about nothing at all, it's been learning to appreciate that it's OK to ask for what I want. And, without expending much effort to ponder this, the "what I want" part has presented itself on its own. Now I could answer the question, without hesitation.
I told him what I wanted. I told him I lacked confidence in working with my hands, and in describing my findings. I told him I wanted experience presenting patient histories and findings to him.
"Done," he said. "We'll do that."
And that night, we did. Right away, BAM. I got exactly what I asked for, just like that.
I didn't always know what I was doing or seeing, and I wasn't always useful. But I was confident enough to ask for clarification or elaboration when something didn't feel fluid. That confidence had absolutely nothing to do with my abilities or some sort of "natural progression" of events; it had everything to do with the deliberate, specific efforts of my mentor to contribute to the deliberate, specific experience I had expressed that I was seeking.
Knowledge is the ability to make the people around you feel smart, after all. One year later, the characters, the experiences, and the opportunities that mark my new life continue to remind me that this move was the smartest thing I've ever done.
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.
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.
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.
Subscribe to:
Posts (Atom)