It turns out that the key thing is to look at the grille shutter to see if there is anything stuck in it. If it’s stuck open there isn’t a problem. If it’s stuck close it’s still not life (or car) threatening unless the engine overheats. Sounds straightforward… but, you have to know where to look.
Since (of course) we were over 200 miles from home when this happened, we went to the local dealer and asked if there might be someone who could look to see if it was stuck open or closed.
“We’d have to run a full diagnostic scan first.”
“But we just need someone who knows where to look to just look.”
“We can’t do that. There aren’t any technicians available and they require the scan first.”
(At this point we decided to take our chances and assume it was open)
“You know, we are both doctors…”
He interrupted to say “So you know how important CT scans are!”
I smiled and said, “Not if all you need to do is pull out a splinter.”
The art of diagnosis in medicine starts, very importantly, with the story. It’s actually astounding how often that will make the diagnosis. At the very least, it narrows down the possibilities. (which we call “the differential”).
The physical exam is next, to refine the differential diagnosis and guide you in deciding which tests to order. Even if the triage team has ordered the tests first (like in a busy ER) it’s still very important to go through these steps in order, starting with a “blank slate” so you don’t fall into the trap of the many ways our brains succumb to bias (especially anchoring bias).
What makes this process, the art of diagnosis in medicine (as opposed to my car) unique is the intent. Because we always go through this process for someone else.We make a diagnosis as the first, important step in healing another human being.
We don’t “diagnose” a bird when we go birding. There are some similarities – We look at “field marks” and listen to the songs the same way we collect data from a patient. We also create a “differential” i.e. the list of birds that fit our findings.
But there’s is one big difference – the intent. Birding is not something we do for someone else, it’s something we do for ourselves.
Photo by Mary Brandt (on the way to High Island via the Bolivar Flats)
There’s a reason so many people flocked (no pun intended) to parks during COVID to take up birding for the first time. It’s a focused way to be outside and experience a little bit of forest (or lake, or field) “bathing”…to connect with sounds and sights that resonate on a soul level.
Anyone who birds a favorite park over and over knows intuitively why they keep going back: It just feels good. Being in nature—pausing in it, sitting with it, discovering its wonders—brings a sense of calm and renewal.
This weekend I went to the beach (which is what we say in Texas, instead of “the shore”). Specifically, we went to North Padre Island so I could give a talk at the Texas Medical Association meeting, but we added a couple of days onto the trip so we could bird.
And boy did we “bird”…
I was introduced to birding by my parents as a child, but my spouse has become immersed in this world and has been a welcome guide and companion as I dipped my toes back into the waters (a pretty good metaphor since a lot of what we saw on this trip were shore birds).
If you are someone who has a high pressure job (like all the healers I know) and very little time (ditto), this may seem like a crazy suggestion… but there are three good reasons you should learn to bird (and then do it):
It’s healing.
What incredible beauty is around us and what a great way birding is to be present to it.
Photo by Mary Brandt
It erases differences.
I am absolutely certain that the people around us had many contradictory views of politics, religions, and all the other points of friction in our society. But none of that mattered. We shared the paths, showed each other birds hidden in the shrubs, and grinned together (a lot).
Photo by Mary Brandt
It reminds me of making a diagnosis.
Identifying a bird is a lot like making a diagnosis in medicine, except when it isn’t. I’m pondering the difference between diagnosis, identification, and discernment (more to follow on that after I think a bit more – i.e. in Part 2 of this post next week).
Photo by Mary Brandt
To make a “diagnosis” as a birder you use field marks, which are a lot like symptoms in medicine – the things you notice and consider before you make a diagnosis. In the case of the bird in the photo above… a bright blue bill with a black tip, a dark eye with a white ring, a slightly brownish long neck, a bluish tint to the head and body, a whitish tuft on the back of the high neck (we would say postero-superior in medicine), and the beautiful fluffy feathers hanging down from the back.
All of which adds up to a Tricolor heron in breeding plumage.
You don’t have to become a “bird nerd” (an accepted and even appreciated term in the community) to bird, but it’s worth learning to pay even a little attention to the birds around us, because it will get you outside, provide you with the dopamine surge you get with any hide and seek game (when you find the treasure), and surprise you with joy.
It’s hard to overstate how incredible this app is… even if you only use it every once in a while (and even if you have no plans to become a birder), you need to have this on your phone.
Borrow a pair, find a used pair, start with a cheaper pair, but be prepared to upgrade – you’ll need to have a decent pair of binoculars at some point.
Based on this review I ended up buying the Athlon Midas 8×24 binoculars, which I love. This particular set of binoculars seems to go on sale fairly regularly for WAY less than their list price, so shop around if these are the ones you decide to get.
Photo by Mary Brandt
“may my heart always be open to little birds who are the secret to living”
CNN recently put out this list of 25 of the world’s greatest sandwiches. Pan Bagnat is listed first. Although their list is not in order of best to worse, it’s where I would put Pan Bagnat since it is my all-time favorite sandwich.
I have yet to find a good Pan Bagnat in Houston (or other cities in the US). The French chefs I’ve talked to say it’s because they can’t get the right kind of bread for a classic pan bagnat. There’s no question the bread in Southern France is better (IYKYK) but really?
In the meantime, it’s never hard to find my second favorite sandwich, which is ubiquitous in Houston… the Bahn mi. If you haven’t experienced this amazing combination of tastes, you are missing one of the best sandwiches in the world. This sandwich comes with more choices (and less oversight) than the French pan bagnat, but you can’t go wrong with the classic version – Bánh Mì Đặc Biệt:
It seems paradoxical to say that paying attention to the moon is a practice that grounds you, but it does. Try it for a month or two. Download an app (this is my favorite app) that can show you when and where to look for moonrise and what phase the moon is in.
Then walk outside and look up for a dose of #MoonJoy.
If you don’t know about the amazing Kate Bowler… you’re welcome! Her take on the “secret of life” (yup, for real) is one of the best I’ve ever heard. (Click on the image to hear it)
“Tiny plastic pellets called nurdles – each about the size of a lentil – are washing up on Texas beaches in alarming quantities. These pre-production plastics are the raw material used to make everyday items like bags and bottles. But when they spill during manufacturing or transport, they escape into the environment, becoming one of the most widespread sources of microplastic pollution.”
This is a scary situation I knew nothing about. These little pieces of plastic “act like tiny sponges, absorbing toxic chemicals such as pesticides and heavy metals”. So it’s not just that we take in microplastics by eating fish that have confused these objects with food, we also consume the poisons the nurdles have absorbed.
A reminder that forest bathing is wonderful (and so easy)
I spent some time yesterday in a park near my home and, while there, decided to try the Japanese practice of shinrin yoku, known in English as “forest bathing.” (Which is therapeutically known as sylvotherapy!)
It’s a practice that involves all five senses, one by one, intentionally…
Listening to sounds, birds, insects, wind in the leaves
Touching the ground, the trees, and the leaves.
Smelling flowers, plants, the dirt
Seeing plants, birds, animals, clouds..
Tasting by breathing through your mouth
If you work in a hospital or another building, a small green area or a single tree will suffice.
We have powerful tools on our digital phones, particularly in medicine. But the relationship with our phones is complicated…and not always beneficial.
The first time I ever came across the word alexithymia was in this New York Times opinion piece about digital phones by Steven Barrie-Anthony. As a physician, I love learning new clinical words with Greek roots – in this case “a” for not, “lexis” for words, and “thymos” which means “feeling” or “spiritedness”. Alexithymia (a word invented in 1970 by psychotherapists), is also known as “emotional blindness”, and means not being able to recognize your emotions.
Dr. Barrie-Anthony noted that the “vast majority” of his patients were experiencing an “alexithymic fog” due to the “gravitational pull” from their phones and social media, a condition that affected “the most important aspects of who they are, their relationships with others and how they move through the world.”
Do we really have agency when we get pulled in by the gravitational force of our phones? For our non-work related time, we pick the app…but then we fall into the dopamine feedback loop of whatever game we’re playing, or algorithms that are foundational to social media.
I think it matters more that I’ve realized, and not for the reasons I thought:
Being used by the tools of the digital world is different from using them as tools because it separates us from our authentic emotions.
“One constant I’ve found is how technology brings a kind of alexithymic fog — alexithymia being the condition of having difficulty identifying or being able to express one’s emotions. This isn’t universal, and the emotions we’re pushing away aren’t always the same. But it happens in a startlingly consistent way.”
To tackle the problems of technology we have to return to our emotional lives for their own sake, and not always leap to doing or changing or fixing. This is the only viable pathway if we are to remain in touch with our humanness and to preserve love, empathy, emotional and spiritual richness, and the capacity to create art and music that reflect our inner lives.
I have yet to experience awe in the digital world.
“When medieval Christians gathered in cathedrals, the soaring architecture and stained glass were designed to lift their thoughts toward the divine. The shared narrative included an image of the good life that directed one to love their neighbor as oneself. Today’s digital architectures are designed with a different purpose – to keep our attention firmly earthbound, focused on consuming content and generating data. The “infinite scroll” isn’t just a design feature; it’s a spiritual technology that trains us to value quantity over quality, novelty over depth, reaction over reflection.”
It is easy to be swept away by fear, to respond to fear with more fear (as well fear’s cousins anger, hatred, and anxiety). This is particularly true right now,when we are contantly confronted with messages of invasion, violence, and “others” who are trying to somehow hurt us. But it’s crucial to recognize that our response to these messages, the fear we are all feeling right now, is a normal, hard-wired, very primal response. When we become afraid, we move automatically – without conscious thought – into “flight, fight, or freeze” mode.
Fear as a response to threat is hard-wired because our response to what frightens us is protective, much like our immune system protects us from bacteria, viruses and other causes of disease. But, like the immune system, if our initial fearful response is not met with balancing forces to “turn down” the heat, fear can destroy us.
1. Realize that your fear is not the “truth”. Recognize it for what it is… an emotional response to a threat (perceived or real). Because it’s an emotion, it can be regulated (not as good as eliminated, but still very helpful). Joan Halifax’s technique which uses the mnemonic “GRACE” is a great place to start.
2. Welcome fear with a sense of gratitude. I know, this seems crazy. Everything in us wants to throw fear out the window, suppress it, rationalize it, compartmentalize it, transform it into anger… anything that makes it seem less threatening. But none of those techniques work. Like making you pull your hand away from a hot stove, your fear is there to protect you. This welcoming practice is a much better way to defuse the emotional impact of fear.
3. Don’t lose your moral compass. Fear of the other is weaponized and used in all societies, but it is rampant now. Don’t let that change your basic goodness, don’t let it force you into becoming someone you don’t want to become. Make sure you articulate and then follow your “true north”.
4. Choose courage. After all of this I have some bad news – You will still be afraid. As Franklin D. Roosevelt said, “Courage is not the absence of fear, but rather the assessment that something else is more important than fear.”
And what are the things that are more important than fear in your life?
What makes up your “true north”?
It will vary a bit between us, but honesty, generosity, integrity, fairness, and compassion tend to be anchoring principles for a good life that are found in virtually all philosophies and faiths.
Choose honesty, generosity, integrity, fairness, and compassion… and then choose to act on them despite the fact that you are afraid.
I started this essay with a quote from JB Pritzker’s recent commencement address …. but there’s another recent quote (unattributed) that also blew me away. It seems a fitting book end to these thoughts…
If you can’t be brave, at least be kind.
If you are interested in reading more about learning to be brave:
Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
feelings of energy depletion or exhaustion;
increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
It took a very ill 10 year old child with perforated appendicitis and Systemic Inflammatory Response Syndrome (SIRS) to make me think about this differently.
As I often do, after my initial visit to the Emergency Room and while waiting for the operating room to get ready, I pulled up UpToDate and PubMed to make sure there wasn’t anything new that might help me take care of this child. As I read, a light bulb went off…
“SIRS is considered a clinical syndrome that is a form of dysregulated inflammation. It was previously defined as two or more abnormalities in temperature, heart rate, respiration, or white blood cell count [29]. SIRS may occur in several conditions related, or not, to infection. Noninfectious conditions classically associated with SIRS include autoimmune disorders, pancreatitis, vasculitis, thromboembolism, burns, or surgery.”(UpToDate, Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis, accessed 7/4/2024)
Which led to an important question….
1. What if burnout is more like SIRS?
If burnout were like SIRS, it could be caused by a variety of etiologies…
SIRS is most often caused by a serious infection. But it can also be caused by trauma (gunshot wounds, car accidents, burns), pancreatitis, burns, inhalation injuries, the “trauma” of major surgery of any kind, transfusion reactions…
What if the same were true for burnout?
What if there were multiple possibilities that could start the cascade from stress to distress?
…and should be understood as the end-stage presentation of a progressive process.
In the case of SIRS from untreated infection, patients who present with seemingly mild symptoms like fever and tachycardia can rapidly progress to sepsis to septic shock to organ failure, and even death.
What if thinking about burnout in the same way could help us understand the progression healers experience from distress to suffering to burnout?
2. The treatment would start with resuscitation (and rapid diagnosis).
Patients with SIRS are hospitalized and aggressively treated with oxygen, fluids, appropriate medications to stabilize blood pressure and antibiotics to treat possible infections. All of this takes place while appropriate exams are being done to find the source of the problem.
What if we approached burnout in a similar fashion? What if, when we first noticed the symptoms ,we provided appropriate “resuscitation” and started looking for specific etiologies?
3. The definitive treatment would be “source control”.
For a patient with SIRS, once we make a diagnosis, we seek to eliminate the source of the SIRS. For appendicitis, we take out the appendix. For pneumonia, we prescribe appropriate antibiotics, and use supplemental oxygen and chest PT as needed.
“Source control” for burnout would be no different. Specific treatments would depend on identifying the specific issue(s) that started the cascade of distress and suffering.
4. Full recovery would require supportive care.
Source control starts the process of healing, but healing is not something we do for or to a patient. In clinical medicine, we facilitate the patient’s ability to heal … and then we support them while they heal.
Burnout should be no different.
I mentioned the need for a good “differential diagnosis” in order to identify the source of SIRS
Which leads to the next important question.
What’s the differential diagnosis for the causes of this syndrome?
I’m sure there are others, but the major categories of insult and injury that I believe should be included in the differential diagnosis of healer distress and/or burnout include:
Failure to recover from injury (physical, emotional, and spiritual). For example, pronouncing a child dead in the ER and then having to run to clinic because you are now late and patients there are getting angry.
Moral distress, injury, and outrage. Moral injury occurs when we know the right thing to do, but can’t do it. For example, not being able to perform an important elective surgery or prescribe a needed medication because it is denied by the patient’s insurance.
Trivializing the sacred nature of healing. For example, the hours spent typing trivial information (for billing) into the EMR.
Secondary trauma from chronic exposure to suffering or specific traumatic events (like the death of a long-time patient or being sued)
The structural violence experienced by being marginalized at work and/or in society (racism, misogyny, homophobia, etc)
You’ll notice lack of self-care and insufficient resilience aren’t on this list.
I believe that insufficient self-care is most often a symptom and never the cause of burnout. That being said, I don’t mean to imply that self-care isn’t important. (You can probably tell I think it’s important just by scanning through the other entries on this blog!)
I’ve come to understand that insufficient self-care should be seen as a “comorbidity” for those in the grip of distress, suffering and burnout…similar to how having diabetes makes it harder to recover from physical illness or injury.
As for resilience… There are no human beings more resilient than those who choose to heal. The idea that insufficient resilience causes burnout is just not true. But itis true that this idea has been weaponized by the institutions who employ us to deflect from the real issue; We work in systems that create moral suffering for those who care for the ill and injured.
What should we call this model?
As I began to think more about using SIRS as a way to think about burnout, I realized I needed a name for this concept. I started with “PDS” for Physician Distress Syndrome, which I loved because PDS is my favorite suture. But a good friend, who works as a nurse practitioner, pointed out to me that this wasn’t just about physicians. Good point. She also said, “But you don’t have to change the acronym! You can call it “Provider Distress Syndrome”.
But I never use the word provider.
Everyone who works in healthcare in the United States (and to a lesser extent in the rest of the world) is affected by these issues. It’s too burdensome to list everyone when we are talking about this – but we need a word that describes all of us.
“Provider” is out.
“Clinician” works, but it is too narrow (and too cold).
The only word I’ve come up with so far that works is “Healer”. So for now, I’m using “Healer Distress Syndrome” to describe this model.
By the way, if you recognize yourself as being somewhere on the continuum from distress to suffering to burnout, you are not alone. Every healer I know is currently or has been there.
You matter.
Your work is sacred work.
We need you.
If you are suffering, please reach out to someone and/or seek professional help.
Most of us have the idea that keeping a journal involves a lot of time. For healers and healers in training that is one thing we don’t have… time. So here’s some realistic advice on how to approach journaling. Give it a try. I promise, it’s worth it.
How
Here’s how to start. Download Day One on your phone and computer. Read the (very short) instructions. This app allows you to use your phone (and/or computer) to write or dictate on the fly, as well as when you have more time. It also lets you easily include photos, links, and audio files. I’m sure there are other apps that do similar things but this is one I know is fantastic (BTW I don’t have any connection to this company).
If you are worried about security, you won’t be honest in your journal – which is important. Make sure that, like this app, whatever technology you use has the security of face recognition and passwords. That being said – even though it should (and will) be very secure, keep HIPAA in mind. No names, photos, or anything that might directly identify a patient!
Don’t worry about long entries. Use your journal as a “Captain’s log” – just a timestamp and a few words to jog your memory. Make an intentional effort to notice good things in addition to the things you struggle with.
0845 OR crew dancing to YMCA before the patient arrived
1015 Boring rounds, but team is cool. Really bad dad joke from Joe.
p.s. Save your journal as a password protected PDF on your computer and resave it frequently. #BackupsAreCritical
Why
Getting past deficit framing. Human beings “deficit frame” by default. Stated another way – we are programmed at a very primitive level to look for anything that might hurt us. As a result, we tend to remember bad things more than good things. Journaling helps keep the balance, and reminds us that we have the power to override our primitive responses to look for mystery, joy, and laughter in our days. It is also therapeutic – Journals let us look for patterns in things that distress us and give us the ability to “talk” these issues out.
A diary for important events. As healers we learn constantly. There will only be one time something is a “first”…the first patient you examine as a medical student, the first murmur you hear, the first chest tube you put in. Write down what happened and how excited you were! Keeping a log/journal like this is also a wonderful way to realize how much progress you make as you advance in your training/practice.
Venting. As human beings, we need a (safe) place to vent. A password protected journal is perfect. Try freewriting – just let it rip without any editing or thought. Even better – vent on a separate piece of paper that you rip to shreds and throw away when you are done… then turn to your journal to describe what you said and did.
Some other thoughts
Gratitude. At the end of every day (or at 2am if you are awake on call), force yourself to write down three things from the day that gave you a sense of gratitude. There are good studies that show this is a powerful tool to ward off burnout and decrease depression and anxiety. It’s also a wonderful way to keep deficit framing at bay and remember why we do what we do.
Mindfulness. This kind of journaling is also a great way to practice mindfulness. In addition to your “captain’s log”, look for moments where you are “between” things, and use these moments as a mindfulness tool. Just stop, take a couple of deep breaths and notice what’s around you.
1620 In the airport, sitting in a food court.. There are a few families, a table with what I assume are work colleagues, an older gentleman with his hamburger (dinner?) who is taking a break from work. I wonder why someone his age is working? There must be a story. There are smiles everywhere. A TV behind me is discussing sports – specifically field kicks in football (which seems a little strange in basketball season?).
Prompts. If you find yourself stuck, try using these questions. Consider writing them down in the morning and then set an intention to answer them at the end of the day. They will float in your subconscious during the day, leading you to look for stories, delight, surprises, and things that need healing.
What story from the day warrants telling?
What delighted me today?
What surprised me today?
What needs healing today?
The world is bursting with wonder, and yet it’s the rare productivity guru who seems to have considered the possibility that the ultimate point of all our frenetic doing might be to experience more of that wonder.
I had the honor of speaking at the American College of Surgeons this week on a panel about stressors clinicians have control over i.e. can modify. I was assigned a topic I had not really thought about before – which meant I learned a lot! After the talk, there were many people who came up to me and asked if they could have my slides… so here they are!
This is a really important concept… worry is an intrusive thought, which means it just pops in your head. And it’s unpleasant, so you worry about worrying!
Another important point here – worrying is always about something in the future (as opposed to rumination, which is always about the past)
These are the two main ways worrying helps us – motivation and emotional buffering. The motivation part is pretty obvious. Emotional buffering is also obvious, but I didn’t have a name for it before. Take for example worrying that you will fail a test. If you end up getting a good grade on the test it is somehow even more exciting… but, if you do poorly your disappointment is somehow buffered.
In terms of emotions, control is the opposite of worrying. Take the test I mentioned above. If you are worried you will fail it, the way to deal with that is to regain a sense of control. For example, using smart notes to optimize learning during your rotations, using this plan to ace your in-servce exam, or this plan to get ready for exams during basic sciences.
This principle holds true for ALL clinicians – no matter how long your have been in practice.
And then I tackled the next question… what to do when worry begins to spiral.
I introduced this validated tool to see if your worrying has crossed the line to problematic or pathologic.
And pointed out that if worry is causing you to suffer, it’s a problem.
The way to deal with problematic worry is to try to return it to the kind of worrying that helps us, which we can do with any action to control what we are worried about. Worried about a test? Make a plan for how and when to study. Worried about a relationship? Plan to meet or pick up the phone to talk. Again – no matter what your are worried about – do something to create a plan to address the worry.
But despite our best efforts, the spiral of worry can land us in a bad place. If you find you have anything on this list (or if you are really suffering), it’s pathologic worry.
It’s super important that you act – quickly. This is your amygdala trying to hijack your brain! (Remember flight-flight-freeze?) If you don’t derail it quickly, it will continue to spiral and land you in a world of anxiety. In other words, follow all the steps for problematic worry – but if it doesn’t work, don’t wait. Get help.
We’ve all been there (yes, all of us). Something happens and we can’t stop thinking about it. It can be a complication, a misdiagnosis, something that happened in a toxic work environment, a failed exam, a harsh word. Not being able to let go of these thoughts means you are a normal person who cares… but it is not comfortable.
It will stop. At the time you are caught in the spiral of rumination, it seems unending. But it can’t and won’t last forever.
You are not your thoughts. There are your thoughts (and this annoying thought in particular) and then there is “you”. Hold that thought (then see below).
Don’t make it worseby yelling. It’s human nature to try to push an uncomfortable thought or image out of your mind. But it doesn’t work. Yelling at yourself (in your mind) because you are not able to move past the thought/event makes it even worse.
Get curious. Berating yourself makes it worse, but there is a way to disarm the thought and even make it go away:
When the thought arises, just notice it.
Wait….if “you” are noticing it, then the thought isn’t “you”.
Exactly.
Every single time the thought arises, say to yourself “I’m thinking about it again.” But – and this is the most important thing – when you notice that the painful thought is back, you have to notice it without judgment. Not… “I can’t believe I can’t let go of this thought.”…or “Something must be wrong with me.”… Just “There it is again.”
Image from multiple internet sties
Mindfulness. The practice of noticing without judgment is called mindfulness. There are good data that an informal practice of mindfulness helps when we find ourselves with a thought that won’t let go. A daily practice helps even more. Set aside just 10 minutes and sit still. Just notice everything that comes up, acknowledge it, and don’t judge. Ditto for the next thought, and the next, and the next…
Here are some links if you’d like to learn more about mindfulness:
