Still flowering

I recently received some anonymous feedback wishing for me to "create better boundaries" in my scope to focus more on my "areas of passion". I found this both shocking and saddening and have been reflecting a lot on this perspective. Is the era of the full-spectrum family medicine physician ending? 

I find it disappointing that some folks feel we need to "specialize" in something within Family Medicine. The truth is, having great breadth to my practice as a "comprehensivist" is my passion and I am specializing - in primary care for all ages. To have a day that can involve a well child check, OB visit, joint injection, counseling a patient struggling with depression, and a heartfelt discussion on end-of-life wishes, all while teaching a couple medical students the tools of my trade - that's pure joy for me. Sure, it's exhausting as heck and I need time to replenish myself when I get home, but I'm getting a lot better at filling my cup back up so I can keep pouring for others. 

I'm a fairly open book about the human issues I deal with - from working full-time while parenting two young children, to navigating a neurodivergent household, to struggling with self-compassion and taking rest, to healing from childhood trauma, to embracing a queer identity that many folks don't understand or acknowledge. I own this authentic approach because I know I'm not the only person living an imperfect life and trying to find my way through. I trust that vulnerability builds connection. But it does also risk the fact that others will make judgments based on what they see. I accept it and have no regrets.

Maybe this person also saw me juggling a shocking list of commitments in medical education and scholarly work as an academic physician - this year alone, I'm president of the San Diego Academy of Family Physicians and busily coordinating our annual conference, completing the Sanford Compassionate Communication Academy Fellowship, serving as Well-Being Educator for the American Academy of Family Physicians and Wellness Director for UCSD's Department of Family Medicine, disseminating important findings from wellness work through scholarly channels, mentoring students and residents in their own research endeavors, developing a new FM clerkship and compassion curriculum for the School of Medicine, envisioning care workflows to better meet the needs of gender-diverse patients, and not to mention all the teaching at the med school and with our residency program. 

Believe me, my resident/student evaluations often come in late and sometimes chart notes stack up (especially if I have to stay home with a sick kid), and I always manage to submit work *right* under the deadline. But the important stuff - like being fully present with my patients in the exam room, helping my learners continue to grow in their clinical identities through teaching and actionable feedback, supporting my colleagues who are going through tough times, and spending quality time with my family -- the human stuff, I think I'm doing OK.

I have been transfixed by my son's pumpkin plant that's been growing in our home. It's easy to get distracted by some of the wilting leaves and not notice the ever-lengthening vine that is starting to flower. But that's life, isn't it? Sometimes things have to wilt a little in the juggling game of life, but if we stay true to what matters, we can still find ourselves flowering. It's a delicate balance and I'm constantly fighting a momentum towards overwork and overcommitment, but I can say with certainty that this busy woman is focusing on her passions. And there's much more to come.

Breathe, and notice

I recently attended a “roll and release” class at a yoga studio, using massage balls to release tension. I was so pumped to work out some of the kinks in my body, but little did I know that some life philosophy was coming my way. As I settled in on my mat and tried to maneuver awkwardly over one of the spheres, the instructor encouraged us to go slow, breathe, and notice. 

Go slow. 

Breathe. 

Notice.

Those simple but wise words started turning over in my head and have become a mantra for me this past week. 

Sometimes when we are going through hard things, we are so focused on feeling better and getting away from discomfort that we don’t take the time to understand what is truly going on. Maybe it’s because we fear what we might find… but the fear and avoidance often turns out to be much worse than meeting our pain with curiosity. There’s a famous saying, 

Suffering = pain x resistance.

I really don’t want to avoid my pain- more and more as the years go on, I realize the wisdom and power that has emerged in times of pain when I just.. opened to it. More on that later.

So during the class, I really made a point to compassionately seek out my trigger points and meet them gently with a little pressure and patience. With time, there was release and I found myself feeling more open, nurtured and grateful. 

By meeting our pain points with an open-hearted tenderness, we  can achieve greater understanding through this focused introspection. And maybe, just maybe, we can also prevent the deep scars of avoidance that inevitably emerge when we turn away from it.

The power of primary care, mentorship, and wellness

It is truly an honor to assume the role of President of the San Diego Academy of Family Physicians this year. This is my acceptance speech from the Installation of Officers event.

It is an exciting time to be stepping into the SDAFP presidency role, with new opportunities as we enter a period of new normals. As we find ourselves armed with more resources to continue forward in the fight against COVID, we also might find ourselves feeling more empowered to connect with others and restore a sense of community that was strained these last 3 years. I’m hoping that SDAFP will begin to host more social events again for those looking to reconnect or meet with other family docs in San Diego. I hope we can come together more often and build up old and new bonds with awesome FM colleagues across the county. 

Now, I take this privilege of representing all of you very seriously and am very open to hearing ideas from folks on where we want to use our momentum this year. From my point of view, I have three main areas I’m hoping to focus on: increasing awareness of the power of FM, strengthening the primary care pipeline through mentorship, and increasing focus on physician wellness.

It is one of my passions to spread the magic of Family Medicine to current and future physicians and the general public- anyone who has seen my posts on social media knows that I unabashedly post on the regular about my #FamilyDocJoys. I think in general we are all too humble about the incredible feats we pull off in our lives as clinicians, educators, scholars, advocates, and so much more. It is such a joy to publicly brag about all my favorite people in our specialty who are moving mountains, and I encourage you all to join me in this collective uplifting of colleagues and the beauty of the work we do. Don’t be shy! What we do is awesome and we need to talk about it more!

Another area ripe with potential is building a stronger pipeline into our specialty - and I’d argue that effective mentorship is crucial to help achieve that goal. I’ve been communicating with the rising FMIG leaders at UCSD SOM and it just further reinforced to me that if we can create some powerful links with students earlier in their education, we have the capacity to connect more amazing future docs into FM. Whether it’s speaking on a panel for National Primary Care Week, or simply getting a cup of coffee with a couple students, putting a face to the work we do can be so powerful. The risk of primary care erasure is palpable across the country and while we need to advocate for strong primary care education in med schools (something that we are actively working on at UCSD), we are all capable of making an impact on the individual level with every student we meet.

Lastly, I’d like to make a few comments about another passion of mine- physician wellness. I have served as Wellness Director for UCSD’s Department of Family Medicine for the last four years, and have seen the power of institutional investment in primary care and its impact on physician wellness. I was also fortunate to be a part of the AAFP’s Leading Physician Well-being program, which has provided additional insight that I hope to share with our members. I hope I can inspire colleagues to employ innovative strategies to support their wellness during an especially challenging time in health care. I have felt the potential for individual and systems approaches to revolutionize our care delivery, our working relationships, and our quality of life. This openness to seeing and practicing things differently is so crucial as we continue the movement to improve physician wellness in our specialty and in our lives.

Whether it’s leveraging social media to raise awareness, writing resolutions or lobbying on issues impacting our work, mentoring students and residents, or advocating for what we need to thrive as family doctors, we have a tremendous capacity to make an impact and shape the future of our specialty. I know I don’t need to overstate this because you all get it, as enlightened and empowered folks doing the good work both in the exam room and out. So I encourage you to continue using your primary care power - inspire others to explore leadership and advocacy and amplify the important work we do. And I am so excited to be on this journey with you.

Boundaries, or lack thereof

Confession: I surf, scroll and check. It’s a compulsion and applies to my social media, work and personal email, and even the EMR because I have an Epic app on my phone. I get secure chat alerts on days off asking me to do things for my patients. I oblige more than I should. It doesn’t seem like much in the moment, but I can’t deny that the thousand micro-crossings of my personal boundaries and well-being must take a toll over time. People talk about not checking email on nights and weekends and while in theory I support it and secretly aspire for it, I simply haven’t been able to imagine an existence where that’s possible. 

But I think it’s time. 

I logged onto the EMR from my phone just to see if there were any new results that popped in (in retrospect, why?? Am I really going to act on them on a Sunday?), and remembered one of my medically complex patients was hospitalized. I figured I’d hop on her chart to see how she’s doing as I know it had been a bit of a tenuous course for her but I thought she was on the mend. As I was opening the chart, I got an alert that said,

You are about to open the chart of a deceased patient.

My heart dropped. I closed the EMR. My day was suddenly shrouded with grief over this longtime patient of mine, as well as sadness for her surviving family members who are also under my care. I regretted the thoughtless choice to open Epic on a day off when I was home with my family. And suddenly I realized how desperately I’m in need of some clear boundary settings to protect my heart and stay present rather than worry about my patients when I’m with family. 

This is one of many #EmpathProblems that I expect I’ll write more about in the future. To feel so deeply about the folks I care for can be incredibly fulfilling and make the job even that much more of a calling, but it can also be incredibly draining. It’s important to compartmentalize deep emotions I have about my patients when necessary to go on living non-doctor parts of my life. But I also recognize the need to feel and process hard things my patients go through. To set some clear boundaries like avoiding compulsive EMR and email checking, silencing push notifications on my phone, and setting away messages when I’m “off” can be important steps in creating a bit more healthy separation. 

I can’t undo the heaviness of the loss of my patient today, as much as I wish I had learned of this when I was in clinic and able to process it more effectively in my workplace. For now, I will accept that this grieving day I’m spending with my family was a hard lesson that I finally allowed myself to learn. I will never shed my doctor self fully no matter where I am, but I’m hopeful that small steps in setting boundaries can help me nurture the other parts of my identity that help me live the full life I dream of.

You're in charge of you

Some people turn to alcohol, recreational drugs, or overconsumption of food as a way to fire their dopamine reward pathways. My issue? I'm a recovering workaholic. 

Well, let's be honest - I still work way too hard, but I can't deny how much my work gives me joy. To be there for people during some of the most vulnerable parts of their lives - from welcoming a baby into the world to holding space for someone thinking about leaving this world - it is an incredible privilege. It's truly rewarding to be this anchor for folks - but it's a double-edged sword, as we can take on so much and not see ourselves buckling under the pressure.

It's easy to make yourself last when everyone/everything else is consuming your attention. Caregivers, I see you! I am on a constant journey of figuring out boundary setting and recognizing my limitations as a human being. It wasn't until I started treating my self-care like work - with scheduled exercise, recuperation time, and healthy lifestyle goal-setting that I started feeling like I had some efficacy in my own life and wellness. Weirdly, I think I kept waiting around for someone/something to hold me accountable to get myself in gear. Who/what was I waiting for? 

At the end of the day, you have to remember that you are in charge of you. No one else can make you decide to give yourself rest, nourish yourself, heal from trauma, or optimize your well-being in general. I think so often we de-emphasize it in this work-obsessed world we live in because there aren't deadlines around our lives. I mean, one day we do die, but we all assume it is far away, that we have all the time in the world. But that's never a guarantee. Sometimes horrible things have to happen to us to really reorient - whether it's losing a loved one, going through a major personal health issue, or having our lives upended in some major way. We can't fall prey to the assumption that there will somehow be time in the future. Because what if there isn't?

We don't have to let a morbid obsession with our mortality guide us, but I do feel that if we are able to wrap our minds around the inherent impermanence that is our lives, sometimes this can help us stay in better alignment with what truly matters. Mindfulness and meditation can keep us more grounded, humble and grateful, and I am striving to make that more a part of my life. By conscientiously plugging into our existence more and taking time to reflect on what matters, we can be true to our north star and also have just a little more impetus to take steps to ensure we are doing what we can to stick around in this life.

Here's to continually learning and growing on our own wellness journeys!

Running through the pain

I’m not a runner. But I strive to be healthy (at times) and will jog every once in awhile, and it is generally awesome. Once I get past the puffing and into a rhythm, those endorphins kick in and I am soaring. One day, I was going at a good pace and suddenly felt a searing pain in my legs and was faced with a decision- do I run through the pain, or let up? I tried to push through for awhile but it really didn’t feel right and I finally slowed down for awhile that the pain settled down and I was able to finish my workout. Later, I was realizing that I probably had shin splints and taking the rest had been pretty crucial to not injure myself further. Yet, I had so much inertia that wanted me to ignore those pain signals and push through. Why?? I can’t help but think some of the values of the Culture of Medicine played a role.

The culture of medicine is strong and thick and hangs on you years after training has ended. Most of us come to the field because of our desire to help others, but the risk of losing ourselves in the process is substantial. 

We love the challenge of this work- flexing our cognitive breadth to limits we never imagined, learning more and more while simultaneously realizing the vast knowledge that still remains unknown to us. In the quest for understanding and becoming the best clinicians we can be, we easily put our needs on the back burner in service of others. We want the best for our patients, so we give our very best, sometimes until we have nothing left. We often find ourselves wearing our sacrifices like a badge of honor- going months without a vacation, responding to messages late in the night, saying yes to something even when you have no remaining bandwidth… 

We come to see the hard work as admirable, even if it slowly peels away at our morale and makes us lose pieces of our non-medical identity in the process. It renders us at high risk for burnout/moral injury, depression/anxiety, even suicide. Physicians are at least twice as likely as the general population to die by suicide. We lose about one physician a day to suicide here in the United States.

Isn’t it horrifying that those who are tasked to heal and keep us well are struggling so deeply? 

It is a scary situation we are in, that has only been amplified by the pandemic, and it can seem like an insurmountable problem. How do we heal the healers? How do we help make people feel whole again, and set healthy boundaries, and thrive in this vital work? I grapple with these questions regularly in my work as wellness director for my department. And for a long time, I felt like the world rested on my shoulders with this wellness quandary (which seems so silly, but I see now that it was my own baggage I carried with my taking ownership of too much and not accepting what was feasible for a single human). The fact of the matter is wellness is a team sport - we have to do our part to see our pain and not just run through it, and we also need our system to support us in not pushing ourselves to injury in the first place. (More on this in my “Putting the 'We' in Wellness” article for the San Diego Physician magazine.)

It’s a tough balance- finding the sweet spot between stretching our boundaries to learn, grow, and engage deeply in healing work, while also not depleting ourselves to the point of no return. And this is why things like peer support, engaged leaders, and evidence-based systems strategies can be the guardrails for us so we don’t try to walk that fine line alone. As with any complex health issue that I manage for a patient, I always say, you have to come at it from all angles to really get a handle on it. In this way, the synergy of multifaceted approaches can become an excellent strategy in the quest for well-being.

Casting off

Why is it that finishing something can feel so overwhelming? There’s something about closing the chapter on something that can be not only intimidating but practically instill dread in the procrastinating individual.

Case in point- I had been working on a simple scarf for my daughter for the longest- knitting a few rows here and there over the last year or two, wondering if it was long enough, and Harper finally said, “Mama can you just finish already?!” I hemmed and hawed and made excuses about how I didn’t really remember how to cast off (nothing a simple YouTube search couldn’t fix, of course). She literally created a motivational sign for me that said, “You Can Cast Off!”, prominently displaying it so I couldn’t avoid the task any longer.

So I sat down and finally finished the darn scarf. She wore it proudly and my guilt of this unfinished business quickly melted away. So why do I put myself through such misery- whether it’s the manuscript that hasn’t been submitted to a journal, unfinished clinic charts, an email draft to an old friend, or even a new blog post? I consider it remnants of a recovering perfectionist. Getting things *just right * sure got me far in my career in medicine, but maladaptive perfectionism is its own burden that can limit one in sending their thoughts into the universe. 

2022 is winding down and I’m looking at what intentions I hope to set for the new year. And I think I’ve got a good one- trusting myself to finish. We can’t let the fear of imperfection paralyze us from sharing things that are a little raw - because who  knows if those rough thoughts might impact someone else in a positive way? So here’s to finishing up, speaking up, and releasing a little goodness into the world in the process.