Put Down The Knife

“Life begins when you put down the knife that you’ve been holding to your own neck.” – Elizabeth Gilbert, author of Eat Pray Love

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Elizabeth was addressing the crowd gathered for O Magazine’s 10th Anniversary bash in New York City, using her signature blend of truth, humor, and self-compassion to remind us that in our quest to “live our best lives”, we can easily fall prey to perfectionism, trying to fix everything that we find broken, and holding ourselves hostage to our own ideal images of who we believe we should be.

It’s a challenge in our culture of extremes to find what feels like balance for YOU. We’re being told by a lot of people what balance “should” be, and given formulas for how to achieve it. Go to a retreat center. Get a massage. Hire a life coach. Read this book. Watch this video. Join this community. Listen to this teacher. It’s enough to make you feel so overwhelmed that keeping the status quo seems a whole lot easier than trying to do something about it.

Right now, I’m in a deep practice of rethinking my thoughts, observing how my responses to situations are governed by a few deeply rooted beliefs that I never had an awareness of until my own experience with burnout led me to my training as a life coach. For me, I have noticed that by believing three main thoughts, I experience most of my feelings of stress, overwhelm, and resistance to what life brings my way.

1. “It’s never enough.”
2. "There’s not enough time.”
3. "I am responsible for other people’s pain and suffering.”

As I write them and look at them now, they still cause me twinges of pain. They are the three different knives I’ve been holding to my own neck, to borrow Elizabeth Gilbert’s image. Maybe you can imagine similar thoughts that you’ve had, and how they land in your body as sensations – a knot in your stomach, a crook in your neck, a clenching in your jaw. When taken to the extreme, any one of these thoughts feels like the threat of my imminent demise. It can cause me to freeze up, become silent, and wonder why I bother to say anything at all.

When I first started to notice these thoughts, the first thing I did was disbelieve how powerful they were as forces in shaping my life. “It’s only a thought,” I thought to myself. I blew it off as no big deal. I tried to take big, bold actions to show how free I was of these limiting beliefs. Limits, me? No way! And what happened? The same thoughts came back in different situations, causing me to behave in similar ways and feel similarly to the way I did in previous situations.

The second thing I did was to be a very dutiful student of the process, coming up with “perfect” turnarounds that showed how skillful I was at mastering the tool. To the first statement, I said, “It’s always enough.” I basked briefly in a moment of triumph for stepping into such power with an abundance-filled affirmation about how the universe always provides, etcetera. But, as my coach pointed out, that is a bunch of baloney if you don’t genuinely believe what you’re saying. Until you look for the evidence in your own life that shows how a turnaround is true, it’s only words on a page.

Busted!

I found this other turnaround to be just as true for me: “I’m never enough for me (my own standards).” Yet another proverbial knife to the neck that I’ve been holding. I can find the truth that I’m never enough for my own standards, and my mind proves that true by preventing me from taking the risk of stating what I really want. If I never set that lofty goal, then I’ll always have a reason to say I haven’t met it. I’ll never be enough for me, as long as that’s what my mind still believes.

For me, the hardest challenge - the thing I think I cannot do - is doing less. And being OK with that being enough for now. Not taking responsibility for other people's feelings or fixing them. Doing my best in each moment, and trying to learn. Now I see that every time I say, "This is enough!", I am one step closer to believing that I can be enough for me. Each time I say, "This is enough!", I am closer to putting down the knife. And it ain't easy!

Who would you be without these thoughts?

When you’ve been walking around holding a knife to your own throat, you don’t just drop it when someone tells you to do so. You may recognize that you don’t like the sensation, but you also don’t know another way. You’ve grown accustomed to “living on the edge”, motivated by the fear of never being enough, running out of time, or being responsible for other people’s opinions of you. These thoughts have gotten you to a certain point in terms of getting a certain job, the approval of family, the image of success, or the apparent ingredients of happiness. To question them may feel like something you might not survive.

Well, you’re right. Part of you – the ego identities associated with those beliefs – will die. But if you’re willing to go through the “death” of disbelieving your painful thoughts, what’s left is the clean, clear mind that gives rise to peace, no matter what circumstances you find yourself in.

So it’s not a new set of instructions, rules, or formulas to follow that will give you what your soul wants. It’s not another idol to worship, or a teacher to please, or a parent to plead for love from. The soul’s nature is to be free and at peace. All you need to do is clear the obstacles.

And put down the knife.

Photo credit (used under a Creative Commons license): Pierre Vignau

The Benefits of Failure and Imagination: JK Rowling's Two Life Lessons for Harvard grads

In her June 2008 commencement speech at Harvard, JK Rowling reminds fledgling Harvard graduates that they may be driven as much by a fear of failure as a need to succeed. She describes her own failure, finding herself seven years after college graduation a divorced single parent living in poverty, as the "rock bottom which became a solid foundation upon which I rebuilt my life." In our quest to climb the next career ladder, to appear "put together" in all aspects of our lives, to create images of ourselves that measure up to our ideals, what parts of our humanity do we miss? A beautifully written talk.

J.K. Rowling Speaks at Harvard Commencement from Harvard Magazine on Vimeo.

Revolutionizing Medicine…One Belief At A Time - Part 1

If you have behaved yourself into a situation, you must behave yourself out of it! The behavior in this case is the behavior of the mind. As a physician, you went through systematic training of the mind to get you to believe certain thoughts. When was the last time you questioned one of these thoughts?

Learning that the mind's natural tendency is to attach to certain thoughts and believe them; and observing that the root of all painful, stressful feelings is believing certain thoughts, was revolutionary for me. I uncovered a system of thoughts that I believed without question, and realized that I already had all the freedom I was longing for. I simply had to question my thoughts.

To show you how this process works, it's best to use real examples.

Each week I’m going to take a stressful thought that is central to the physician’s belief system, and question it. Follow along, and even listen in on the audio podcast as you do your own work on the same thought.

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*This process is based on The Work of Byron Katie. For more information, visit www.thework.com.

A list of physicians’ common stressful thoughts:

“I need to take care of patients.”

“I am surrounded by illness, suffering, and death.”

“Patients demand my time.”

“People need me to respond.”

“I need to fill out paperwork.”

“There is too much paperwork.”

“My job is stressful.”

“Medicine is a stressful profession.”

“I don’t have enough time.”

“I have too many patients.”

“I am responsible for my patients.”

“I am responsible for keeping my patients healthy.”

“I am responsible for alleviating my patients’ pain and suffering.”

“I can’t make a mistake.”

“I need to do the right thing.”

“I work too many hours.”

“I don’t get paid enough.”

“I don’t get enough respect.”

“I need to be more efficient.”

“I already paid my dues.”

“I sacrificed myself to become a doctor.”

“I’m dealing with life or death issues.”

“This is more than just a job.”

“I need to find meaning in my job.”

“I’m too busy.”

“It’s not worth it.”

“I trained all those years to be able to do my job.”

“I’ve worked so hard already.”

“I can’t give up my job.”

“I need to put my training to good use.”

“I need to put the patient first.”

“My needs are secondary to the patient’s.”

“The system needs an overhaul.”

“I am a doctor.”

Can you come up with any more, based on your own experience?

Make your own list, and follow along as I question each of these thoughts.

Today's thought: "I need to take care of my patients."

The questions:

1. Is it true?
2. Can you know that it is absolutely, 100% true?
3. How do you react, and how do you behave, when you believe the thought, "I need to take care of my patients"?
4. What is the payoff you get for believing the thought, "I need to take care of my patients"?
5. What are you afraid might happen if you didn't believe the thought, "I need to take care of my patients"?
6. Who would you be, and how would you behave, if you didn't believe the thought, "I need to take care of my patients"?

Now turn the thought around, as I have done below. Find three genuine examples in your life for how each of these new thoughts is as true as the original thought.

• "I don't need to take care of my patients."
  • Examples:
  • Some common complaints and illnesses (upper respiratory infections) resolve themselves on their own.
  • There are some issues impacting a patient's health that cannot be solved by a doctor's intervention.
  • I can choose not to be a doctor practicing clinical medicine and taking care of patients.
• "My patients need to take care of themselves."
  • Behavior changes such as exercise, smoking cessation, and diet are examples of how patients can take care of themselves.
  • Giving patients the tools and information to take better care of themselves is a recognized need in improving health care.
  • Patients can improve communication with their doctors by being more informed and asking the right questions.
• "I need to take care of myself."
  • As a doctor, I am a model of health to my patients.
  • If I am tired and depleted, I have limited capacity to take care of another person.
  • The way I lead my life sends a powerful message to my patients, to my family, and to other doctors.

Take the time to find examples that feel genuine to you, and that come from your own life.

Notice where you are facing resistance to this process, and when your mind wants to "speed up" rather than find the examples.

Creativity: A Prescription for Doctors

If you asked most people if they value "creativity" in their doctor or surgeon, I'm guessing most people would say “NO.” (Tell me where I'm wrong.) I used to think that there were certain professions – like medicine - where creativity is actually not a valuable attribute. I'm beginning to wonder if that's really true.

Are mistakes always bad?

Most of us think that medical mistakes are all bad. That the last thing we want is for our doctor to "make a mistake". Well, I'm beginning to think that by making mistakes "bad" we are limiting the creative thinking that we really need from doctors. Especially now.

One of the big walls in my mind that was completely blasted away during my year of training as a life coach and certification in sound healing was the idea that all mistakes are “bad”. First, I heard story after story from real people describing how the biggest “mistakes” in life often turn out to yield unimaginably rich treasures later on (an assertion confirmed recently by Conan O’Brien at his visit to Google). Then, when I began making improvisational music, I realized that some of the most expressive sounds come from playing the “wrong” notes. I slowly began to see how just that thought – “Mistakes are bad” – leads us to hide the things we don’t know, be afraid of asking for help, and remain closed to new ways of doing things.

Medical training doesn’t encourage creative thinking

What I never saw encouraged in the first two years of medical school was any kind of creative thinking. The selection process to get into medical school, and the evaluations throughout the process, rely heavily on multiple-choice tests and promote the belief that physicians always need to be "right".

But I always knew intuitively that clinical medicine is an art. I wondered at what point in the training this shift from "being right" to "practicing an art" would be instilled in us.

Maybe I didn't stick around long enough in medicine to see for myself, but when I looked at the residents and fellows in training around me - the ones who were supposed to be my mentors – many of them walked around like the living dead. They appeared to divide their time between trying to look good to the person just above them on the hierarchy of authority, and trying to get home from the hospital at a decent time each day. In their spare time, if their eyes were actually open, they would look pityingly at us medical students, occasionally sharing a story or two about how someday we would also have the starry-eyed hope beaten out of us.

When I think back on those days, I wonder how they might have been different if the training culture (starting in medical school) had treated the idea of "mistakes" in a different way.

What if…?

What if people, at every stage of their training and practice of medicine, were expected to make mistakes? What if the number and type of mistakes you made (and shared openly with others) were a measure of the quality of your learning? What if you had to make your mistakes publicly, and everyone in the room was invited to give feedback? What if everyone – from student to resident to fellow to attending -- had to do this?

I’m borrowing this model from a source that may surprise you – the internal practices of Pixar Animation Studio. Ed Catmull, President of Pixar, wrote a Harvard Business Review paper and recently gave a talk I attended at Stanford University on the elements of success at Pixar. How is it that the studio has managed to produce such a steady string of consistently blockbuster movies (Toy Story, Toy Story 2, Monsters, Inc., Finding Nemo,  The Incredibles, Cars, Ratatouille, WALL-E, and Up), each with an original storyline developed in-house?

The answer surprised me.

Catmull described a culture in which each of the “What if…?” questions I asked above was answered with “Yes.” Contrast these attributes of Pixar's culture with the typical training environment for a physician.

• Expect to make mistakes. Everyone at Pixar is taught to expect things (using Catmull’s language) to “suck” at first. Everyone also learns early on that the path to “not sucking” (ie, being good) always starts with “sucking”. Young doctors live in perpetual fear, clinging to the notion of needing to be “right” all the time. The training environment should reassure them that the more wrong they are willing to be at first, the better chances they have at improving over time.
• Fail publicly…early and often. It is an accepted part of the culture at Pixar to show your unfinished work to peers on a daily basis to receive feedback…even when it sucks. These gatherings are called “dailies”. Everyone does this, so that inhibitions about “being the only one who sucks” are let go, and trust is built. Doctors-in-training are constantly playing a game of “looking good” in front of the more senior person on the totem pole. There is little to no value placed on peer feedback, even though the daily patient rounds are a perfect setting for this to occur.
• Open communication. At Pixar, the film’s director has final decision-making authority; however, everyone in the room is encouraged to give feedback during dailies. “Brain trusts” of senior members on other teams are convened when one team needs help on a particular problem. In medicine, it is rare for a student to directly address an attending physician. There is a clear hierarchy of roles, which usually mirrors access and communication.

Catmull admitted to a challenge now that certain Pixar executives have achieved “legendary” status. When it’s observed that feedback is being held back because of the presence of certain “legends in the room”, the meetings are scaled back to two or three people, in order to create a safe environment for feedback to flow….even when it sucks.

“Going to Hell in a Handbasket”

Asking what might happen if the medical training culture began to place a greater value on creativity, making mistakes, and learning through open communication, probably induces in some the kind of fear associated with the apocalypse. That’s because it would mean the end of one way of thinking. It would threaten the age-old structures that have governed our assumptions, expectations, and ways of measuring outcomes. It would surely induce some people to say, “We’re going to hell in a handbasket!” But aren’t we already saying that about our health care system?

Learning versus Performing

The “learning” environment in medical training is actually a performance environment, even though we call it the "practice" of medicine. As a medical student, real practice and learning is expected to be done in private - reading and memorizing - while the actions of “being a doctor” are presented as "show time" -  when you try to impress the person above you with how much you already know.

So back to my list of “What if…?”s. The whole list can be boiled down just to this: What if doctors were trained to be more creative? I can imagine some simple steps that any clinical team could implement tomorrow on morning rounds.

• Start by acknowledging that all doctors are humans. No one - not even that surgeon who acts like he owns the hospital (and maybe he does) - is going to get it "right" all the time. This is a hard one, I know, but you'll never get to the other steps without swallowing this pill, so do it now.
• Mistakes are not inherently bad. It's how we handle our mistakes that develops our creativity and leadership potential. So stop fearing and start making mistakes. And then...
• Talk openly about what went wrong, without blame or judgment. Show your work, explain what you see, and ask for feedback. What information was missing or misinterpreted? Who could be called in for additional help? What step in the process could have been handled better? Get everyone at every level involved in this process. No one is immune to making mistakes, and medicine desperately needs open engagement among all levels of professionals and staff.
• Repeat this process daily. Someone wise once said, “If you have behaved yourself into a situation, you must behave yourself out of it!” Just as the existing culture wasn't created in one day, implementing this into the daily routine will take some time and practice. But with this small shift in attitude, every day is an opportunity to build your creativity muscles.

If medical judgment could be cultivated merely by performing "perfectly" in front of your superiors for a number of years, then how do we explain the high levels of physician burnout, patient dissatisfaction, and medical errors in our health care system today?

The culture of performance needs to be balanced by a culture of learning and creativity.

If medical training began valuing creativity from doctors, we might have more vibrant and collaborative health care teams whose focus was the patient, and whose willingness to learn would produce better health over time…one mistake at a time.