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A thought is like cotton –

it can be processed hundreds of times and each time it becomes more refined.

On Creativity, Inc.

I joined a book club for a national conference for SGIM 2016! And, I thought the choice of the book was interesting. The night before the book club meeting, well past midnight, I finally finished the book and realized that I felt inspired.

Books offer a new world of thoughts, ideas, and inspiration. Ed Catmull in Creativity Inc. has laid out the truth about organizations and happiness on the personal and professional fronts. I am sure that many book critics and experts can truly dissect the anatomy of this book, and probably much more accurately than me. However, I wanted to share a few themes that left me inspired as a physician and as a person.

Empowering quality inherently

Catmull writes about giving ownership and responsibility of a product’s quality to the people who are most involved in its creation. According to him this “resulted in continuous improvement driving out flaws and improving quality.” He takes the example from other industries and applies to animation. When I read this, I wonder about the multiple businesses that choose to pursue errors and mistakes in a responsible and candid fashion. How did they start their journey? How did they overcome obstacles? And, how did they strengthen this system over time. In medicine, we routinely care for people across their life-cycle, birth through death. Some of the actions we take have significant consequences on people’s lives, including patients, families, and colleagues. However, have we evolved into a system that chooses to empower by allowing candor when quality is at stake? Healthcare should look to evolve into a system that allows those who work within it to report flaws and thus allow continuous improvement. This requires alignment on internal and external factors if we are to be successful.

Unbalanced Life 

Our lives are unbalanced right now. We have this sense that in order to be successful and proud of our productivity, we must be dedicated to our work above and beyond any other commitment. Is this true? As Catmull states,

“if we are in this for the long haul, we have to take care of ourselves, support healthy habits, and encourage employees to have fulfilling lives outside of work.”

Fulfillment outside of work is hard to attain and harder to require. Physician burnoutdepression, suicides, and shift work are some of the phrases we hear commonly now in medical literature. There is a plethora of ongoing research in this realm, yet, we are not able to solve for the “x”. What is the x-factor? Why do physicians cope with life in medicine in varying degrees? How can we make personal fulfillment be acknowledged as a step to professional fulfillment?

Fail early and fail fast

One of my favorites! This is a very important motto in this book and credited to Andrew Stanton. Catmull explains that failure is akin to

“learning to ride a bike; it is inconceivable that you would learn to do this without making mistakes be wrong as fast as you can.”

The concept is that when you are in pursuit of a goal, you must start somewhere. Start and then see how things go. At the worst, you fail. But, you can always decide to try again in a more novel way. The most basic example of this in medicine is running ACLS codes. Circulation is key and the goal is to start compressions if no pulse. Then, if you think there is a shockable rhythm, deliver shock. Still no pulse? Start again! Beyond the ACLS codes however, this is not as apparent, although it is embedded in most of our processes. On a personal front, this is so important to me. I remember planning my wedding and I toiled with the ideas of centerpieces. Daywere spent deciding which flowers, colors, height. But at some point, we picked one and moved on. Was it tough to pick one? Yes. Was it life-altering? No. Lesson – pick one and move on!

On Mental Models (my absolute favorite!)

“We are meaning making creatures who made other people subtle clues just as they read ours. All we need is a tiny bit of information to make huge leaps of inference based on our models.”

That is true! Furthermore, in the book, they mention that less than 50% of what we think we “see” comes in through our eyes; the remainder is constructed from patterns and memory. Can you believe this number? If our feedback to others is based solely on our sight perception, how can we be sure we saw what actually occurred. Think about it this way: I can remember where I parked in a large airport parking lot for a total of 10 mins. When I come back from a 2-day trip, I use my parking ticket with space number to recall where my car would be. If I am asked to provide feedback to  a resident from an event that occurred few days ago, how much of my perception is now accurate? More so, how much of my previous interactions with residents will influence how I remember the event? And if my perception is an approximation with 50% chance of being incorrect, then,

“the conclusions we draw cannot be helped but be prone to error.”

In medicine and medical education, we should be acutely aware of this phenomenon. What we “see” is not actually what we “see.”

Catmull has discussed many more ideas and concepts on being a more “creative” organization. Like he says, this book is not meant to give directions on how to grow creativity, but how to enrich the soil in which creativity can grow. He provided an avenue for his best people to share their best ideas and their mistakes. Of course, I am not going to list everything because I want you to go read the book. This is a FANTASTIC book for ANYONE! Why? Because it makes you think about the movies you love the most. Because in this book Catmull helps us realize that the animation process is exactly that, it is a process. It has a beginning, middle, and end. Everything that happens in those stages is the true magic – the magic of coming together as people, not employers and employees. But as people with an ability to create and the need to experience fulfillment.

Pixar Slide

Woof!

Seven years ago today, life changed. I was a new sister for a little puppy – 8 weeks old, size of my fist, and by all measures a fur ball. First weeks consisted of sleeping, pooping, eating, and then sleeping again. But time flies fast and now he is 7 years old!

It is so difficult to express the connection between humans and dogs. My favorite dog book by Cynthia L. Copeland, “Really important stuff my dog has taught me” is simple, just like my dog. It paints the tales of numerous ways dogs have truly changed the lives of their humans. But still, it cant possibly capture the emotions our relationship encompasses. I can only describe it this way: when I am having a nightmare and unable to wake up, my dog will cuddle up next to me and all of a sudden the nightmare ends, both metaphorically & in reality. When I am with my dog, I know I am loved without condition or prejudice. I know I am loved more than I can possibly love another.

Until one has loved an animal, a part of one’s soul remain unawakened. – Anatole France

In honor of my puppy’s birthday today, I thought I would share some studies published over the last few years documenting the effects of the relationship between dogs and humans.

What are the effects of dogs on humans? Humans are social animals and we all agree that socialization offers psychological and physical benefits. McConnell et al (2011) decided to study whether dogs can fulfill one’s social needs? What they found was astounding only to those who do not have a dog. Pet owners had greater self-esteem, greater conscientiousness, less fearful attachment. In addition, “the support that pets provided complemented rather than competed with human sources.” And finally, pets have the ability to “stave off negativity caused by social rejection.” For this reason, it is no surprise that many children and disabled support groups advocate for the use of pet therapy dogs. The 2015 study by Gadomski et al, showed that although children with a dog did not differ in their overall Body Mass Index (BMI), “having a pet dog in the home was associated with a decreased probability of childhood anxiety.”

What about our effect on dogs?  Tuber, et al (1996) observed the level of glucocorticoids (cortisol) responses of domestic dog pairs when they were separated in a novel environment. When separated, the dogs showed showed increased activity and elevated glucocorticoid levels. These responses were “as large when the dogs were with their kennel mates as when they were alone.” When the pair was separated but teh remainin K-9 was in the presence of their human caretaker, “activity and glucocorticoid levels were not elevated …dogs more often were observed in proximity with, and soliciting social behavior from, the human than the kennel mate.” Conclusion: human companionship for the domestic dog is important and there is a difference in the nature of the social relationships of dogs with humans and with counterparts.

What does all this mean? Should we run to the shelters and adopt dogs? Should we measure our neuronal actions or maybe measure the secretions of endorphin when we play with a dog? Should we help people afraid of dogs move past their fears and become reacquainted with the K-9 species? Should I prescribe some K-9 therapy for all my patients with chronic diseases, especially depression? Should we have dogs visit classrooms in every school or maybe provide a program for schools with high events of bullying or childhood anxiety/depression?

If I had a magical power, I would say YES! to all and there would be happiness everywhere! Alas, I do not have the magical powers. However, I do have the power to encourage and mentor any and everyone who is thinking of adding a dog to their family. It is a big decision to make. It requires deep thought about the breed of dog, the space available in your home, the time commitment, and the health needs you can address comfortably. I cannot assure you that day-to-day is easy. But, I can assure you that it will be the best decision you can make!

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  1. McConnell, AR., Brown, CM., Shoda, TM., Stayton, LE., Martin, CE. (2011) Friends with benefits: On the positive consequences of pet ownership. Journal of Personality and Social Psychology, Vol 101(6), Dec 2011, 1239-1252. http://dx.doi.org/10.1037/a0024506
  2. Gadomski, AM., Scribani, MB., Krupa, N., et al. (2015). Pet dogs and children’s health: opportunities for chronic disease prevention? Chronic Dis. 12: E205, doi:  10.5888/pcd12.150204
  3. Tuber, D., Hennessy, MB., Sander, S., et all (1996). Behavioral and glucocorticoid responses of adult domestic dogs (Canis familiaris) to companionship and social separation. Journal of Comparative Psychology, Vol 110(1), Mar 1996, 103-108. http://dx.doi.org/10.1037/0735-7036.110.1.103

A Call for Physician Advocacy

It is not every day that I get to hear the US Surgeon General address physicians, and when given the chance, I can’t resist the offer!  At the SHM 2016 meeting, Dr. Vivek Murthy “rallied the troops” behind many thoughts, two of which included advocacy and kindness (check out separate blog post on kindness).

I am an advocacy enthusiast. When I speak with medical students or residents and colleagues, I draw a parallel between advocating and playing on a sports team. In both advocacy and sports, the ultimate outcome does not drive the effort; rather the effort is driven by the potential of making a difference for your team. Advocacy does not come with a guarantee on the results or policy that I hope for, but I always walk away with the feeling that I fought a battle worth fighting.

Similar to Dr. Murthy, I wish that many more of us physicians showed up to the game as active participants. I recognize that physicians, leaders, and my colleagues show courage daily as they make decisions that effect lives. And I know that they have the same courage to come out of the shadows and express their thoughts, no matter how naive, cynical, or dissenting from the mainstream.

Medicine has never been an exact science because humans are not exact replicates of each other. The diversity in medicine keeps all of us interested in case studies and reports. Similarly, each of us has a unique idea processing center. This diversity of thought needs to be cultivated and expressed. Afterall, I think we owe it to our patients, colleagues, and ourselves to share and discuss ideas that may be the next great debate in healthcare.

You’ve got a friend in me

I sat sprawled on the cold, clammy floor. The room had the smell of fresh raindrops on the ground mixed with old pages. On this sleepy summer afternoon, I was in paradise – the library!

I came to America as a 9 year old skinny kid. It was a brand new city, new people, new lifestyle. I spoke the language or at least thought I did (after all I knew how to spell most of the words in the English language!) But, it was still the toughest time of  my life. I had no idea about the latest movies or TV shows. I did not know how to play the games during recess. And, I had no friends – literally no friends. My mom told me stories about crying on my way home after-school because I talked to no one and no one talked to me during school. It was a pretty desperate situation, and my teacher soon realized it. I was the kid in the corner – quiet, shy, and terribly afraid. One day she decided to bring me to the library during recess and asked me to pick an animal I wanted to learn about more. I chose one – the panda! And, she gave me a book, I took it home, I read it. The following week she brought me back again, I chose another animal, read the book and I returned it the next day. My mom realized that I had stopped crying at home, and now I wouldn’t stop talking about animals. This cycle went on for 2 months, and then school ended.

I was devastated.

I had no Mrs. Axelrod to bring me to the library and lend me a book. I was now at the mercy of my neighborhood kids. As I cried (again) on my way back from school, my mom surprised me with the best gift : daily trips to the library for a few hours of reading. And that summer, I made my first friend in America: Sarah. You may know her as Sarah, Plain and Tall.

You see, books provided me a comfort that no one else could – they spoke to me like friends. I could be lost in our conversations for hours. They were always there for a rainy afternoon or a sleepless night. Sarah, Mary, Francine, and Joe* were my 4 best friends because each of them was a young misfit girl with life issues. And each of them, taught me the same thing: stand tall in face of adversity, be open to new thoughts, and be true to yourself. When I think of books today, I think of the vast landscapes, fantastic kingdoms, and unique cultures I have visited through them. I think about the precarious journey of time that they have helped me traverse. And mostly, I think about the girl I would have grown up to be without these books. I could still be the quiet, lonely kid on the playground sitting in the corner, feeling lost and abandoned. But I am not because I had these early friends who gave me the comfort I needed when I was too scared to ask for it.

Today on #worldbookday I say thank you to all the authors and characters who have helped young women find their identity and be proud.

Books became her friends and there was one for every mood. There was poetry for quiet companionship. There was adventure when she tired of quiet hours. There would be love stories when she came into adolescence and when she wanted to feel a closeness to someone she could read a biography. On that day when she first knew she could read, she made a vow to read one book a day as long as she lived.” – Betty Smith, A Tree Grows in Brooklyn

* Sarah, Plain & Tall, The Secret Garden, A Tree Grows in Brooklyn, and The Little Women

New Year = Old & New Books!

I realize now that I have been going through “book malaise” towards the mid/end of 2015. As the winter has rolled around, I realize I am missing dear books. I started 2015 with a bang – reading a lot and hoping to get through a list of books. Somewhere along the way, a greater distance between myself and my darling book-list. Why? Maybe the moving, graduating, traveling, and getting married interrupted the routine a bit. However, January is back and so is my great expectation of finishing another set of books this year! And, like always, V provided me the inspiration by giving me a phenomenal book to read – The Shed that Fed a Million Children  – more about that book a little later! So, after being inspired to read a whole lot, I have managed to narrow down another list. Yes, some of these books I did not get around to reading last year. So if they sound familiar, they are.

2016 Reading list:

 

In full disclosure, I should state that I have successfully finished two of these books (In Spite of the Gods and The Shed that Fed a Million Children) since they were truly started in 2015, and I loved them both!  (check out later posts for reviews on those books!)

Here’s to another attempt at keeping up with a New Year’s Book List!

The Common Indian – Story 2

“He is really nice to me. My first husband used to get angry and hit me a lot, especially when he would drink. He died – he drank himself to death.” This is Lila. She is young, beautiful, and a wise sage at only 32 years old. Her life experience makes her a lot older than her numerical age. She was born in the eastern state of Odisha in a “small regular village – cows and farmland.” She moved to Delhi with her then husband at the age of 16 years old, where she lived on the streets before moving to the slums outside of Noida. It was not long before her husband started drinking and became unemployed. Within that year, she had her first child and decided that she would not raise her daughter in this poor slum – so, she left her infant daughter with her in-laws in Odisha ot be raised without her presence. She returned to find her husband gone and her effects sold, likely by her husband in exchange for alcohol. After being on the streets again, she started working in local houses and restaurants to wash dishes, clean bathrooms, and mopping floors. Having saved enough to move back into the “tenement housing,” she describes evenings that consisted of verbal and physical abuse from her husband. After hearing this, I could not help but compare my life at the age of 18 to Lila’s. I was living in perfect happiness going to college, deciding what color my bed sheets would be, and what I should do on Friday night with my friends. This thought line is does not cross into the realm of homelessness, abuse, domestic violence, and unsafe living conditions.

As I spoke with Lila, I became more appreciative of her strong will and character. She had two other children (daughter and son) but had to send her daughter to live with an aunt in the village because she feared for her safety when her husband was intoxicated. Lila describes her husband’s death as both traumatic but also liberating. She cared for him as he slowly became weaker, jaundiced, and unable to eat or drink anything. He eventually passed away in her arms. After his death, she describes finding the strength to live on her own with her infant son. She continued working, was able to get a small shack of her own, send money home to her daughters, and began planning to send her son to school. Eventually, she re-married. This is where I see her eyes light up. I can appreciate the happiness that her current husband brings her. She describes him as “patient and calm. He never yells at me, even if I argue with him, he still does not yell back. He works hard during the day and cares for my son like a true father. He is a good man.”

When I ask about her daughters, there is sense of melancholy. She explains that she misses them a lot – only visits once a year. When she calls on the local phone, they are too shy to answer, especially her older daughter. “My middle one is smart. My oldest one is timid. I think she is a lot like me when I first got married. She quietly listens to everyone and never says anything back, even when someone is yelling at her or being unfair.” Similar to any mother, she has many concerns about the future of her children – their life, their education, and their marriages. On the forefront of Lila’s worries now is her older daughter.

“I worry about her. She is going to be 17 years old, living with her grandparents. It is not safe for an unmarried young girl to stay at home in the village. I constantly worry that someone may hurt her. So, I think we are going to get her married soon.”

There is a long pause as Lila finishes wipes off the jasmine oil from her fingers, likely thinking about the future.

When I ask her about the future wedding and her gift to her daughter, she explains

“I have nothing to offer, except this advice: do not be afraid of anyone, especially her own husband. In marriage, she needs to speak up for herself and not allow her husband to hurt her, like I did. You see, I am not educated. But she is. She knows more than me.”

Humility and concern are probably the most apt traits to describe Lila. Her life would make the average person angry with the world, yet she lifts her head and moves along, perhaps for the sake of her children. It makes me happy to think that she has found a partner who can help heal the deep wounds. She is certainly a testament to the human spirit, and I pray that Lila’s path forward is filled with more happiness than her past.

The Common Indian – Story 1

The twinkling lights of Marine Drive glowed in the dark. U maneuvered the car with the ease of a skilled surgeon. He could map the arteries that supplied the heart of downtown-Mumbai and avoid the veins that were congested with traffic. He had seen it all. Born, raised, and bred in the humid air off of the Arabian Sea, U took great pride in introducing his city to us. He showed us the Chowpatty Beach and explained that the life and times of Mumbaites were chronicled in the sands of the Chowpatty. He pointed up towards the glass towers erected by the Ambanis, Mittals, Tatas, and other socialites. He proudly offered to introduce us to the music scene of India from the comforts of the backseat – pop, jazz, hindi new & old, classical, rock, hard rock, metal, hip hop, and of course instrumental. He was proud. But when it came time to talk about himself, he was reserved, almost timid.

U tells his story in a concise and uneventful manner. He does not divulge details unless asked. He does not offer stories unless prodded. And he certainly does not occupy by mentioning frivolous facts about his “mundane life.” Ironically, V & I were most interested in knowing him and his story. We had seen plenty of shiny ivory towers and its surroundings. We wanted to know more about the life and heart of Mumbai – its people. So, after much querying, we discovered that for the past 8 years, U works as a driver for a popular luxury hotel. He lives on the outskirts of Mumbai and takes the commuter train into the central/downtown Mumbai, approximately a 40min train ride, and then walked 15-20 mins to the hotel. Here, he changes into his uniform, cleans his car, and finally receives the assignments for the day. His shifts are supposed to be 12 hours at a time – starting at 7AM or 10AM. However, this particular night, he is assigned to us and thus working overtime while providing us the night tour of Mumbai. And, what a tour it was! With the reflections of the city’s tall glass buildings in his eyes, he said “I was born here.” As his voice trailed off, I wondered whether he wanted to say “this city belongs to me and I to it.” There is so much more to the story of U, and this visit only provided a small glimpse of the true Mumbai and its Mumbaite. The rest of the stories are saved for our next trip.

We are the world

It is a momentous week – world leaders are getting together for the UN Summit week, Pope is visiting NYC, and Autumn is finally arriving. For me personally, this is momentous because I remember being excited about the UN Millenium Goals and now I get to witness the reveal of the Global Goals!

What is different between then and now? Well, I am older, the UN week is still the world attention holder, but the goals have become much bolder! The new goals are fantastic because they push the limits of the nations’ leaders to achieve these goals. More importantly, they include topics that were left to the wayside the last time – responsible consumption & production, life below water & on land. I am enthralled as I think about being part of a generation that can witness the achievements of these goals. Of course, the obvious caveat is that many of these goals are closely dependent on the mothers of all goals: peace & justice – leadership from strong institutions.

UN Global Goals

As you notice in this pictograph, peace & justice are listed as goal #16, while the plan is completed by the goal of creating global partnerships. This is such a vital distinction because the success of achieving these goals is soundly dependent upon our ability as humanity to unite for peace and justice. One cannot be achieved without the other –

“Peace without justice is tyranny” – William Allen White

When we listen to the news on the radio or peruse through a magazine or the lonely newspaper – everyone notices the headlines. Based on today’s AP News headlines, I created word cloud (helped by worditout.com). Of course the usual common words are predominant – day of the week, politics, Congress, news; however we should take notice of the following words: Syria, US, military, combat, Russian, injured, war, missions, flee. We seldom come across words like peace, happiness, camaraderie, partnership.

WOrd Cloud

It is clear that the state of our world is not adequately depicted here. I recognize the commonly accepted explanation that unhappy news sells while happiness does not ignite a fire. However, we should ask ourselves whether each of us is truly doing our part in cultivating a community that is inclusive and tolerant of differences but not injustice. We need stability to achieve all the goals outlined above – and stability is achieved only in areas where justice prevails. Each continent of our world is affected by instability. The Global Conflict Tracker is a tool produced by the Council on Foreign Relations, and take a look at their prediction of conflicts for 2015:

Conflict map

To the folks who believe that nations should focus on their individual priorities – think about this: is there any denying now that conflicts on one continent are affecting the interests of all? We are no longer the citizens of individual countries – we are global citizens. When the dividing lines of mother nature’s geography do not amount to any effectiveness, why do we still allow political and religious lines to divide us? If we are to achieve the goals of zero poverty, zero hunger, we need to educate our next generation. If we are to achieve educational goals, we need safe places for our children to study, eat, live, and prosper. These children will look to us to provide by example – the example of peace, justice, industry, and acceptance.

Reading furnishes the mind only with materials of knowledge. It is thinking that makes what we read ours. – John Locke

Does each of us have to go out to a warn torn corner of the world? No. We need to find the opportunities in our own towns and cities to promote each of these goals. Work as a mentor or teacher, help build a community garden, urge your companies to invest in the local resources to decrease unemployment, donate materials to build food pantries & home, and most importantly, bring awareness!

The world is round – a globe – thus our efforts of achieving these goals should be global!

Atlas Shrugged

“I am a doctor…a doctor. I went to medical school, not computer or business school.”

Does that sound familiar?

Of course it does! As a newly minted attending, I can say that I have heard those words from my former attendings and my colleagues during residency. We have to understand that those words mask a growing sense of frustration, apprehension, and sadness. They are reacting to the perception that the skills they spent decades on perfecting are less valuable in the eyes of the payers. At this time, the doctors think their ability of checking boxes and responding to electronic alerts is significantly more valued than their ability to coach a patient through surviving cancer or taking their medications everyday.

Everyone likes the feeling of belonging, of using their skills for good. If you asked a pastry chef to spend half his time billing his customers rather than creating a cake that rivals the beauty of famous paintings, I assure you the chef would quit that job. (Fortunately, they could move into Brooklyn and open another gourmet Bake shop!:-) )

Now, imagine the frustration of a physician asked to rush through a patient visit, only to spend more time completing notes and clicking more check boxes. Those lost moments are precious for patients and physicians. There is a thread that ties a patient and physician together – it is made of mutual respect, appreciation, understanding of values, and most importantly time. Today that essential thread is a little thinner. A part of humanism is simply lost in the hustle between patients. There is increasing recognition that healthcare provider burnout and stress is surreptitiously plaguing our healthcare industry. We see the effects on the looming/anticipated physician workforce shortage.

You may wonder – is the solution to simply increase patient time visits? I am not sure that would singularly resolve the qualms of modern day patient care.

I think the solution is still to be discovered. In thinking of the solution, my eighth-grade physics project comes to mind – the task was to create an insulation system for an egg so that when it is dropped from the 2nd floor, the impact forces are disbursed and the egg remains intact. So, imagine a patient’s values being the center egg, the expertise of primary care and sub-specialty physicians being the bubble wrap immediately surrounding the egg, and the skills of the interdisciplinary clinic team being the box and package filling that help the egg bounce on impact. Without any of these materials, the egg is bound to crack, and thus we are bound to betray the values of our patient. In order to come up with the solution, we need to recognize that each of the healthcare providers involved have skills that are interdependent.

The team as a whole has to provide for the patient. A physician cannot solely manage the patient, the EHR, the electronic tasks, the prior-authorizations, the billing, all the while screening the patient for cancer and depression. The physician’s abilities will falter and patient care will suffer from the fall. A physician needs time to reflect on the patient’s concerns and read between the lines of patient’s questions. And, we can’t simply require physicians to partner with non-physician providers to complete these tasks, especially when as a society we provide limited resources for that joint venture. Patient Centered medical homes and Advanced Primary Care models are moves in the right direction. However, we do not have the complete solution. I suspect that the solution of the future will be amenable to the needs of the patients and healthcare providers alike.

As we navigate the sea of healthcare delivery, it is important to realize that our paths maybe uncertain but our motivation should be united. For the healthcare leaders of the world, this is the most opportune time to be innovative because small progress will lead to great achievements.

Thought is the wind, Knowledge the sail, and Mankind the vessel. – Augustus Hare

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