The Illusion of Work- Life balance

In Time Management  I wrote about the value of time management as a tool but not as a way of life. In my 30’s and 40’s I applied the principles of time management to “work-life balance.” I reasoned I could balance work with lifestyle by defining compartments in my life and then use the management principles to allocate time and schedule.

I divided my life into various buckets — work, family, exercise and relationships. I then decided how much time I needed and wanted within each category and created weekly schedules in my head. Intermittent feelings of successful balance fueled my illusion that work-life balance was useful and achievable. I would feel “in balance” for a week or two until events disrupted the fragile equilibrium. Work might intermittently demand more time or my kids might be sick or I might sustain a running injury.

And even on the weeks when I felt balanced, I sensed gnawing dread that an event would upset my plan. Perhaps a patient would need to be seen late in the afternoon causing me to miss a soccer game or arrive late for a family dinner. I spent enormous energy creating and maintaining boundaries between the divisions I created.

At times I wanted to do something different than what was scheduled. What if I just wanted to watch TV or read a book rather than exercise or what if I wanted alone time rather than being with my family?

The more I chased balance the more I felt imbalanced and frustrated.

Fortunately in my 50’s I realized the chase was futile and built on misleading assumptions. The very phrase “work-life” pitted work against the rest of my life causing me to frame the wrong questions. In fact, most days I found work gratifying and even on frustrating days, work provided security for my family. In other words, work was inseparable from the rest of my life.

Most importantly, the work-life framework assumed a mentality of scarcity rather than abundance. Allocating time to various aspects of my life meant that time was scarce and I needed to carefully measure and guard how I spent my hours. Indeed, even the phrase “spent my hours” sprang from the scarcity of a limited budget of time.

Gradually I stopped running after balance and shifted from a sense of scarcity to abundance and passion. I found that inviting gratitude and compassion into my life filled me with a sense of plenty. I made certain my days included activities that flowed from my passions which made the concept of work-life balance irrelevant.

Instead of “work-life balance” consider the frame of connecting with the energy and abundance of self, others and meaning. Connecting with self may include regular exercise, formal meditation, walks in nature or simply sitting quietly for a few minutes. Connecting with others may occur by opening to genuine conversation, volunteering, finding community, love or compassion. Connecting with meaning may be expressed through being in touch with what’s just beneath the surface of your work, feeling a part of nature or through a formal contemplative or religious practice.

The passions of our hearts bring energy to the activities of our heads. Please use comments below to describe the passions at work that bring you energy. How do you cultivate the energy flowing from your passions as you put head and heart together?

Clinician Grief

cropped-wave.jpg

Craig (name changed to protect confidentiality) taught me how tough physicians should grieve. They shouldn’t. Craig and I were about the same age, each with sons at similar ages. Craig suffered from advanced lymphoma, no longer responding to chemotherapy. He knew from his shortness of breath and growing disfiguring tumors on his face and chest that he was dying. He asked me to promise, when his time came, to keep him comfortable. I promised.

Late afternoon on a “call day” his nurse paged me to his room. Call days were rough. Each intern typically “worked up” 8-10 newly admitted patients over a 36 hour period and responded to the changing needs of over 100 other patients. Upon entering his room, I knew from his gurgling, irregular breathing and faraway look that he was dying. I remembered my promise as he weakly squeezed my hand. He died a few minutes later.

Aware that I already had two new patients to evaluate, as well as a long list of other tasks, I left the room and headed for the stairs. Alone in the stairwell, I paused — surprised by a single muffled sob rising from my chest. I shook it off and headed to the next admission and, from there, to many more patients waiting to be seen that evening.

The implicit message, “real doctors don’t feel sadness”, I incorporated from those ahead of me in training. One just moves on.

I did not think about Craig again until several years after my internship. I heard the book “House of God,” presented a raucous and hilarious view of internship. Instead of laughing, I wept as I read the book which triggered a flood of memories and bottled up grief. I cried for Craig. I cried for the four year old who was crushed by a car when he darted out into the street, and I cried for his parents, to whom I had to deliver the unfathomable news. My tears felt cleansing as I cried for the many patients who died during my training.

A  study in the Archives of Internal Medicine (Nature and Impact of Grief over Patient Loss on Oncologists Personal and Professional Lives) tracked 20 oncologists for nine months to determine if they felt grief when a patient died and how they coped with the feeling. In a New York Times article about the study, the lead researcher, Leeat Granek, writes that “not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves…More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.”

To avoid being overwhelmed, some physicians and clinicians maintain an emotional distance to cope with a career where they witness so much illness and death. Many clinicians feel they must stay strong for patients and families who are experiencing their own substantial grief. Other clinicians may be reluctant to show emotion in front of patients or their professional colleagues as they perceive this as a sign of weakness.

The study goes on to say “the theme of balancing emotional boundaries captured the tension between growing close enough to care about the patients but remaining distant enough to avoid the pain of the loss when the patient died…patient loss was a unique affective experience that had a smoke like quality. Like smoke, this grief was intangible and invisible. Nonetheless, it was pervasive, sticking to the physicians’ clothes when they went home after work and slipping under the doors between patient rooms.”

Please use comments below to describe how you deal with grief in your professional life.

Privileged Presence

cropped-wave.jpg

The story below, She Sang Him His Life, from the book Privileged Presence:­ Personal Stories of Connections in Health Care, captures my sense of reverence for health care.

Palliative care seems to be a place where anything goes. On our unit, the hours are completely open; people come and go as the need; pets visit. Staff pay attention to so many little details of comfort. There’s a tenderness and kindness on the unit that’s extraordinary. By comparison, when I visit someone on another floor, it’s impersonal, and I feel assaulted by noise, unpleasant smells, and a sense of crowdedness.

One night, I arrived for my regular volunteer shift on the palliative care unit and found the staff in a very emotional state. This was not entirely unusual, but I sensed that something special had happened that day. I was right.
A young man, in his early forties, had been on the unit for several days. His wife had been with him almost constantly. This husband and wife were both from the same tiny village in Newfoundland. They had grown up together, become a couple, gotten married, and lived there all their lives. And now this man, her husband, was dying. She knew that the end was near and asked the nurses if she could get into bed with her husband and snuggle. And the answer was, “Of course you can, dear.”

And then the singing started. It went on for well over an hour. This woman, as she cuddled her dying husband, slowly and gently, sang him his life and their lives together.
When the singing stopped, her husband was still alive. She then sang him permission to leave.

Use comments below about stories giving you a sense of reverence working with patients and families.

Time Management

free-vector-stopwatch_133034_stopwatch

The blog Time  posed the question of our relationship with time–how much do we struggle swimming upstream compared to floating in the currents of time? The concept of “time management” broadens this question.

“Time management” refers to the tools we consciously use to control the amount of time allocated to tasks in order to increase efficiency. How do we use these tools while cultivating our relationship with time?

As an executive, I applied the time management approach of Getting Things Done  by David Allen coupled with the Seven Habits of Highly Effective People  by Steven Covey. Allen’s approach identifies the vague sense of unease we feel because of the scores of poorly defined tasks floating around in our heads– I need to change the batteries in the carbon monoxide detector; that report is due to tomorrow; the staircase in the backyard needs a railing; we are low on cereal; I wonder what that patient’s potassium was?

Many of these tasks create anxiety because they are unformed and not actionable. As a result, we know we should begin but don’t know how. As an example, if our task is to learn how to ski, we can’t proceed until we have defined a desirable outcome–ski the bunny hill during my February vacation- and an actionable next step– find John’s phone number so I can call and ask him which ski school he used.

Allen asks us to settle our churning minds by collecting all of our “stuff” (the pending tasks of our lives) and listing them in one place in order for us to define desirable outcomes and next actions. He then teaches a process to keep work flowing. His approach appealed to my “inner geek” because I was able to use the advanced functions of the Task List in Outlook to manage the activities of my life. I prided myself on having all of my work flowing through one and only one highly customized inbox

The time management approaches of Allen and others are useful tools for productivity but are less so when applied as a way of life. Indeed, time management tools enabled my illusion that I could outrun time and my infinite task list. I imagined that by running faster than time, I could outrun aging. Managing time is a delusion. We can’t manage time. Our planning does not impress time and it flows unceasingly with or without us. Yet action without planning is impulse.

Though we cannot manage time as a way of life, we can work on the kind of person we want to be as we use tools for efficiency and cultivate our relationship with time. I found Covey’s book particularly helpful in this regard. Covey goes beyond the usual time management lists, schedules, calendars and priorities by articulating the following 7 habits to improve our capacity to accomplish.: be proactive, begin with the end in mind, put first things first, think win-win, seek to understand–then to be understood, synergize (combine the strengths of people through teamwork ) and sharpen the saw (balance and renew your energy for a sustainable life-style).

Covey stresses that how we are in time–our character, relationships, attitudes and spirituality is critical for what we do in time..

Please use comments below to describe using time management approaches while cultivating your relationship with time.

Words We Use

wave

Our words direct thoughts and feelings. When interacting with patients our word choices shape our views.

During my formal medical training, I naturally desired to support and understand individuals struggling to adjust to a clinical diagnosis. As an eager medical student, I valued learning how another human being makes meaning from their medical condition. However, the training culture eroded my initial inclinations. I vividly recall instructions during an early clinical hospital rotation. “David, go workup the ‘lunger’ in room 208.” The “lunger”, a 38 year old father of 3 small children , was dying from chronic obstructive pulmonary disease associated with hereditary alpha 1 antitrypsin deficiency. The word “lunger” distanced me from the patient’s anguish and courage in this poignant human struggle.

During the first day of internship, the second year resident instructed me to write a note on the “CHFer” (an individual with congestive heart failure) in room 620. Introducing myself, I noticed the patient was too weak to lift a fork to his mouth to feed himself. Yet, the next day upon entering his room, I noted an open window, empty bed and dangling IV. The patient managed the strength to open the window jumping to his death. Later, I learned this CHFer was in his 40’s diagnosed with a rapidly progressive cardiomyopathy. As a motorcycle racer he jumped over large obstacles with his bike just 6 months prior to hospitalization. The last jump of his life represented the act of a once physically active man exercising his final choice. Categorizing him as the CHFer in room 620 completely obscures the meaning of a bedridden, dependent state for this individual.

I worked up appys, hip fractures, diabetics, acute bellies and numerous other “conditions”. Naming people by their clinical states, we condensed and ignored life experiences insulating ourselves from the patient’s “meaning making.”

Imagine, replacing the standard clinical term “work up” with a request to please “understand” the patient in room 208 who is short of breath with end stage chronic pulmonary disease. The improved training culture would embed the medical evaluation within the context of values and meanings for the patient.

Soon, I internalized the pervasive training culture. Shaped by words, I began elevating clinical problems above “subjective experiences.” Years of clinical practice and personal losses provided the humility for me to appreciate the flaws in this viewpoint. Witnessing the courage of patients and families struggling with loss, fear, confusion and vulnerability, while grappling with my own traumatic health crisis, helped me understand the importance of creating a healing environment and experience with patients.

For many of us, who’ve experienced early clinical training within the traditional medical culture, paying consistent attention to clinical needs arises more naturally than attending to the emotional and experiential concerns of patients.

Please use “comments” below to provide examples of words you use or hear that enhance or diminish the experiences of the individuals we support

Healers and Ritual

 

cropped-wave.jpg

Picture the following doctor and patient interactions from my time as a practicing physician.

Patient A: “Every few weeks, I get a momentary stabbing pain right here on my chest. It feels like an electric shock.”

Dr. A: Already knowing the symptom does not represent anything serious, I listen to the heart and lungs, palpate the abdomen and check knee reflexes.

Patient B: “Sometimes my stools are little and hard. You know, just like a rabbit’s. I have noticed this for 20 years and it has not changed.”

Dr. A:  Already knowing that the symptom does not represent anything serious, I listen to the heart and lungs, palpate the abdomen and check knee reflexes

Patient C: “Ever since my wife died 3 months ago I have trouble sleeping. I am worried that I have a serious medical problem.”

Dr. A: Already knowing that the insomnia stems from grief, I listen to the heart and lungs, palpate the abdomen and check knee reflexes.

After years of being drawn to listen to the heart and lungs, palpate the abdomen and check knee reflexes I felt engaged in an ancient dance. In most cases, these assessments contributed little to my knowledge about a patient’s physical condition. Going through the routine, I felt a subterranean kinship with witch doctors and shamans.

At one point in my career, I felt compelled to learn about ancient healers. I discovered they all had something in common: ritual. Rituals mark the transformations occurring with significant transitions such as birth, death, birthdays, confirmations, bar mitzvah, etc. Listening to the heart and lungs and palpating the abdomen represented an important ritual in applying human touch to transform worry into acceptance.

In a remarkable 18 minute TED talk video entitled “A Doctors Touch,” author and infectious disease specialist Abraham Verghese describes the power of the human hand to touch, comfort and diagnose. (Click here to view). Verghese paints a vivid picture of the everyday health care ritual of patients baring their souls to physicians and then disrobing.

Please use comments below to describe your thoughts about the relationship of healing, ritual and touch

 

Healing Lineage

wave

The healing lineage of physicians traces back thousands of years spanning cultures. We explain the present; we predict the future; we change the future. We forge relationships in order “to cure sometimes, to relieve often, to comfort always.”

When I was a young physician, Dr. Moses Barron, posthumously taught me about healing. I never met Dr. Barron, but received his teachings via a tattered, folded note carried for 40 years in Max’s wallet. As part of an initial history and physical examination, I asked Max the usual question: “have you had any medical problems over the years?” Max said nothing as he reached for his billfold retrieving a handwritten note dated (before my birth) and signed by Moses Barron: “You have nervous bowel. It will flare up whenever you are under stress.” Sure enough, Max suffered symptoms of irritable bowel syndrome, yet never sought treatment, subsequent to Dr. Barron’s inscription. Dr Barron explained the present (you have irritable bowel), predicted the future (you will have symptoms whenever you are under stress) and changed the future (Max did not seek medical help for his symptoms).

Dr. Barron taught me “little things” contribute to healing in ways that we may never observe.

Years later, I learned Frederick Banting, during his 1925 Nobel Prize acceptance speech for discovering insulin, attributed his findings to an article written in 1920 by Dr. Baron.

Please use comments below to describe how “little things” contribute to healing through relationships, explaining the present, predicting the future and changing the future.

More is Magic

wave

I travel through daily life protected by a veil masking the unforeseen that might befall me and my loved ones. Several years ago, the veil temporarily lifted during a single week in December when I experienced a vision problem in my lone good eye, my wife underwent surgery and my daughter, an avid cyclist, sustained a concussion (yes, she was wearing a helmet) requiring a two day hospitalization.

Unprotected, I longed to prevent and control the occurrence of harmful circumstances for me and my loved ones. Throughout history, humans felt this same desire expressed through incantations, prayer, sacrifices, ritual dances, magic and superstitions to ward off the “evil eye.” In healthcare today, this universal need emerges as magical beliefs that “more is better” and “knowledge is power.”

Examples include:

Knowledge is power; uncertainty can be eliminated. Surely more tests lead to greater certainty

Often, multiple testing generates even more uncertainty through “false positives” (an abnormal result when no abnormality exists) or “false negatives” (a normal result despite an abnormality).

An explanation exists as to why I feel this way.

Sometimes with a medical evaluation, uncertainty reins supreme. The probability of developing conditions such as specific cancers, diabetes and heart disease increases with risk factors related to family history, smoking or obesity. Yet, people may succumb to illness for completely unknown reasons. Additionally, symptoms and suffering may exist that modern medicine cannot explain.

Early detection of problems leads to cures.

Although sometimes true, early detection provides no guarantee of improved prognosis.

Don’t just stand there, do something!

Treatments can be ineffective or produce deleterious side effects eroding the quality of life. “Watchful waiting” may at times remain the best course.

As health care tackles reducing unnecessary services (medical services without obvious benefit and with the potential to do more harm than good) we must begin with compassion toward ourselves, patients and their families who, in an attempt to ward off harm, cling to the deep seated magical illusion that “more is better.”

Please use comments below to discuss how you personally and professionally deal with the longing to prevent the occurrence of harmful events.

Shame, Blame and Cultural Humility

Slide03 copy

In recent posts (Cultural Humility and Language and Cultural Humility) I shared that cultural humility begins with recognizing our own silent assumptions that act as blinders. These blinders can inhibit the way in which we glimpse the world through the eyes of others. At times they can cause us to blame patients, shaming individuals in the process.

The blinders of health care which can lead to blame and shame derive from a fundamental cultural assumptions of Western culture– I am in charge and thus have personal responsibility for all aspects of my life. How do these assumptions show up in health care and how do they at times cause blame and shame?

Consider how you think about the relationship of lifestyle to prevention and wellness. Our language related to illness, as I wrote about in “Language and Cultural Humility” tends to make use of military metaphors – health care battles disease. In contrast, when we think about prevention we tend to use a personal responsibility framework embodied in the term “lifestyle choices.”

We assume based on ample evidence that eating the right food in the right amount and exercising regularly prevents problems such as obesity, high blood pressure and heart disease. Don’t get me wrong – focusing on how changes in lifestyle can prevent health problems is useful, but too often we move beyond the evidence and invoke the personal responsibility blinders embedded in the term “lifestyle choices” to judge those who are overweight, smoke or lead sedentary lives. We reason that if regular exercise and a good diet help prevent health problems, and if everyone is personally in control and responsible for their behavior, than obesity or other “evidence” of not following an “ideal lifestyle” must flow from weak-willed lack of disciplined choices. This structure of thinking is equivalent to viewing obesity as a character flaw which then leads to blame and shame.

“Lifestyle choices” represents our Western cultural blinders of control and personal responsibility. We silently say to ourselves that “it is all about the choices we make.” The term also reflects biases flowing from a culture of affluence. We silently assume that everyone can afford fruits and vegetables rather than macaroni and cheese or that regular exercise need not need compete with more basic needs to make it day to day.

I do not intend to diminish “agency,” the sense that our decisions matter. I am suggesting that “agency,” though important, can act as a cultural blinder leading to judgment, shame and blame.

Avoiding the judgmental shame/blame trap implicit in “lifestyle choices” requires us to recognize our deep- seated cultural biases and to replace judgment with curiosity. As an example, the personal responsibility framework is one of many ways to view prevention issues. Like other frameworks it is not right or wrong, rather simply more useful (when it helps prevent health problems) or less useful (when it leads to judgmental blame). Another alternative viewpoint to personal responsibility is that obesity is a species problem which develops from humans being separated from the cycles of famine that marked most of our history. In this viewpoint, humans developed metabolic defenses to cope with famine and now that we have have moved beyond the environment for which we evolved to handle, obesity occurs.

Do you at times judge yourself or others for what you consider ‘lifestyle choices”? Reading this blog, do you find yourself irritated and wanting to assert: “but prevention is about choices and personal responsibility”? (If so, you may have a cultural blinder). Please use comments below to describe your deep-seated cultural biases.

Language and Cultural Humility

Slide10

In my last post, Cultural Humility, based on the book The Spirit Catches You and You Fall Down, I shared that cultural humility involves replacing judgment with curiosity, and begins with reflecting on our own silent assumptions. Another book, Illness as Metaphor, by Susan Sontag, made me realize the depth of my biases and the difficulty of rising above them. Sontag shows how the words we use imply assumptions; language powerfully yet invisibly shapes how we view the world.

Sontag describes how Tuberculosis (TB) was viewed prior to our understanding of its origin and treatment. TB, also known as Consumption, was seen as a disease of a passion. Individuals with TB were “consumed” with unrequited passion. Consumption was viewed as a feature of the romantic artistic temperament, and the gaunt appearance of the “consumptive” became the model for aristocratic looks.

Despite the advent of modern science, we continue to view illnesses through blinders. Consider, for instance, that we use military metaphors to guide our thinking about cancer. Cancer cells invade the body. Individuals fight cancer. Radiation therapy bombards cancer cells and chemotherapy targets malignant cells, though it creates collateral damage of harming healthy cells, leading to hair loss, vomiting, etc. Obituaries describe how a loved one finally died after a long battle with cancer. Indeed, the war on cancer began with Nixon signing the National Cancer Act of 1971 to conquer cancer. We may extend the military metaphor of cancer to all disease: Modern medicine fights illness.

Alternatively, we may view cancer through another blinder: the revenge of an injured environment on thoughtless humans who smoke, eat toxins (saccharin, nitrites, hormone fed poultry, etc.), pollute with pesticides, or overdose on radiation and microwave energy. These military and environmental metaphors can be useful, but they may also be damaging unless accompanied by the humility to understand that they are simply cultural assumptions embedded in language.

Consider the example of my mother. She was at peace after chemotherapy failed and wanted to be comfortable and with her family. A well intentioned busybody harangued her to continue the fight by eating apricot pits and by visualizing her good cells fighting the cancer cells. Implicit in the busybody’s world view was that cancer victims had control–if only they tried hard enough. Although modern medicine uses treatments which are more effective than fruit pits and imagery, the trap is the same. The military view of illness may engender subtle blame, shame and a sense of failure. Progressive illness must imply that we did not fight hard enough or that we developed the cancer in the first place because we were weak willed and smoked or ate the wrong things.

As I read Sontag’s book, I reflected that perhaps our most pervasive blinder relates to the language we use to describe life. The following words demonstrate examples of different views of life embedded in language:

Life is a struggle
Life is a gift
Life is a door to the next life
Life is a journey
Life is a stage
Life is a mystery
Lifee is box of chocolates (and you never know what you’re going to get)

In order to glimpse the world through the eyes of others, we must first see and remove our own blinders which may be deeply embedded in the words we use.

Please use comments below to describe how the words you use reflect silent assumptions and biases which may interfere with your interactions with those who have different assumptions.