Just write

In medicine, we soak up so much suffering on a daily basis. Sure, there is a lot of joy and connection and laughs and inspiration. But the number of times I have felt a patient's trauma in the core of my being is innumerable. The cumulative grief and pain is too much for any human to bear. So we have a few options - 

1. Box it up. Compartmentalize. We all have to do this to a certain extent in a busy work day. We can have a really difficult conversation with a patient on hospice and then have to head into a well baby check, all smiles. But some people continually keep all the hard emotions buried down deep, hoping they will never come out (spoiler alert: repressed feelings often rear their head at the most inopportune times).

2. Feel it all. Have no boundaries. Lose your sense of self. Simmer in the pain of sympathy and notice it creep into all the corners of your life. 

3. Process it. This can look a lot of ways, whether it's a Balint group, therapy, meditation, creative arts, or writing. 

For me, writing is a critical elixir to stay healthy and whole as a healer. When I face hard times with a patient, and I feel the pain gripping my heart in unhealthy ways and sending me on my way to option 2 above, I am called to write. In this way, I can search for understanding in the midst of the suffering, even if it is just trying to make sense of my feelings. This ritual helps me ground myself in a deeper wisdom by metabolizing the pain in my own reflective process.

I have started a tradition of giving journals to my learners, encouraging them to write about their experiences in medical school as a therapeutic outlet, and also to be able to remember some critical moments that might otherwise fade into a distant memory. Many have told me how powerful it has been to journal during such a demanding time of their lives. 

Journaling might not be for everyone, but I do feel that creating space for oneself to process the heavy stuff in medicine is pretty critical and an accessible antidote for cynicism, numbing, and emotional exhaustion.

And I have found it so meaningful to take it to the next level by sharing my story and remembering the common humanity of so many of life's challenges - but more on that another day.

For now, find time to just write. You won't regret it. 

Moving through uncertainty

I was on a solo road trip recently to a conference and at some point on the journey, I was met with a dense fog that cloaked the highway for several miles. It was disconcerting and disorienting, and forced me to zero in on what was right in front of me. The little that I could see had to become my guiding point, and it took a lot of present-moment awareness to stay focused on the path forward, even though it felt very uncertain. 

I tend to be a very future-oriented person, so leaning into contemplative practices like meditation and mindfulness have forced me to embrace some discomfort to see things a different way. I find comfort in planning and looking forward and what’s ahead, to feel more sure in the present moment. But sometimes in life, we will get mucked up in some things that are unclear, dynamic and unexpected. And we have to reorient and ground ourselves in what we do know, even if it doesn’t seem like much. When there isn’t much extrinsic information, we have to go inward to our intuition to guide us. That comes naturally to some more than others, but certainly we can all practice sinking into our inner knowing more often. As social beings, we easily can look outward for guidance on which way to go, but sometimes that takes us on a very different path than we would have chosen for ourselves.

Eventually I did make it through the fog and was able to breathe more easily as I finished up the trip on a nice sunny stretch. It was a little scary, but I was grateful that I trusted myself to move through the uncertain path. I found that it put me in a helpful mindset as I embarked on the wellness conference, trusting my voice more to speak up and connect with new people. When we get comfortable with the unknown a bit more, it really can empower us to meet it with grace in our daily life.

Stuck in knots

Have you ever tried to untie a knot when you are in a hurry or stressed out?

It's super frustrating, isn't it? What ends up happening? You keep tugging and making it worse. 

Silly example - I was trying to undo a tangled up necklace recently when I was running late for something. It was a ridiculous few minutes of struggle until I gave up and told myself that that wasn't the time to do it. 

It's only when you force yourself to slow down and methodically work through a seemingly impossible problem that it starts to unravel the way it should. The old adage is, when you walk into a code blue in the hospital, check your pulse first, then check the patient's. You have to be able to turn inward and settle in to the right frame of mind to show up and do hard things. 

I am reminded of this again and again when I don't give myself space to just be - whether it's meditation, journaling, yoga, or being fully present with loved ones. When you're feeling depleted, it's easy to get caught up in unhelpful thoughts peppered with guilt and worry around unfinished items on the to-do list, unrealized aspirations, self-criticism, and even hopelessness and overwhelm. It can be a vicious cycle of trying to busy oneself to avoid a shame spiral of inadequacy - but it's the same useless coping strategy that keeps us angrily tugging at knots that won't budge. 

But when I allow myself to turn inward with loving kindness and trust that I have what I need and that I am truly enough, even when I feel stuck in knots, that is a powerful act of self-compassion and healing. I think that's why contemplative practices are so radically effective - they ground us in the important stuff while softening even the most formidable obstacles.

So next time you're faced with a knotted mess, put a little trust in yourself to meet it with equanimity. And if you feel like you can't at that moment, sometimes stepping away to get into a better headspace is the right move. Regardless, tough times are inevitable, but how you support yourself in facing those challenges is what really matters. 

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.