Make Your Mark

One of my favorite parts of the day is cuddle time in the evening with our kids as they are winding down for bed. Yawning and cozy, we reflect on the day that's gone and what's to come, giggle, and sing lullabies to each other. I know one day, this tradition will end and I am soaking it up as much as I can. Besides the joy of the oxytocin rush I get with these sweet embraces, I have also been inspired by some of the incredible wisdom that has emerged out of the mouths of these babes...

The other night, we somehow came upon a discussion on the meaning of life, and my 9-year-old said, 

        Maybe it's all about making your mark. 

I was shocked to hear such a profound commentary from my daughter and I feel like it so eloquently described a fundamental aspect of my vision statement for life. While I do feel that finding our joy in life is so crucial, I believe that an extension of that is the impact you choose to have on others as you pursue your passions. When we can follow our bliss and "make our mark" in a palpable and positive way, it can be so empowering for all involved.

It always throws me when patients tell me that some thing I said to them years ago significantly changed the trajectory of their health journey. I mean, we do our best to take care of patients when they come through our doors, but so often it feels that our impact ends there. Hearing these stories from patients is a reminder of the profound effect our words and actions can have, either for good or bad. This doesn't mean we need to walk on eggshells or overthink every single thing we say. On the contrary, when we can truly realize our self-efficacy and capacity for effecting change, we can help more folks take on seemingly insurmountable challenges, whether it is getting a chronic condition under control, facing the end of life with equanimity, or emerging from trauma.

I'll never forget when a patient told me after going through sexual assault that my words of encouragement from a prior visit echoed in her head and empowered her to fight back and save herself. Or the patient who finally quit smoking after the millionth time that I bothered him about it. Or the chronically anxious patient who finally found some peace when she realized her suffering and accepted treatment. These stories can easily become faded memories, but I am challenging myself to hold them in my heart more deeply, so I never lose trust in the power of compassionate presence. Just as these humans found hope and healing through connection, I, too, felt uplifted and inspired - in the human capacity for change and growth, and the part I could play in that process. This is one way that I make my mark. This is a fundamental part of my why. 

How do you make your mark? How do you want to have an impact?

Puzzling as Progress

So I decided to bust out a new 1000 piece puzzle two weeks ago for a fun family activity as the tropical storm was heading towards San Diego. I always associated puzzles with rest, mindfulness, and bonding with loved ones, so I was excited to get started. It was all fine and good at first, until my family members gradually tired of the extremely challenging work of getting the intricate pieces to come together, and they peeled away and busied themselves with other things. Then it became my project.

My partner regularly complained about how it was taking up too much room, and threatened to box it up when I was gone for a conference the following week. But when I came back, it was still there! He saved it for me. It seems like such a silly gesture, but suddenly I was filled with new resolve. If Cory didn't put it away, maybe he thinks I can do this thing after all. I found myself determined to prove that I could finish it. 

Every day, I tried my darnedest to make progress, but it was slow going. I felt the undone puzzle hanging over me, and it seemed weird how much I let it get to me. But it became obvious that the puzzle symbolized something more, reminding me of difficult things that I need to do that I tend to procrastinate or avoid. So every day, I spent some time chipping away at it. At first, I felt like I was barely making any progress. Then I found new approaches like focusing on identifying distinctive puzzle shapes rather than color patterns, or zeroing in on one section of the puzzle, which made me feel less overwhelmed by the more monumental task of getting it all done. I would mess with the lighting in the room or look at the puzzle from a different angle and sometimes that helped me find a path forward. Heck, the kids even joined in sometimes and helped me turn a corner a couple times when I was hitting a roadblock.

This simple puzzle ritual became an exercise in persistence and patience, and really forced me to just trust the process. I came to believe that I could really get it done and started to look forward to my solo meditative time as I slowly put the pieces together. Suddenly I wasn't checking work email after hours or obsessing over my to-do list. And when I did have to buckle down and do some work, I felt I had more bandwidth to complete other responsibilities because I had been committed to this "non-productive" downtime which naturally created some healthy boundaries between work and home. 

So, 13 days later, the puzzle is complete. I admired my work, and the finished product was missing two pieces - no surprise with two young kids and a playful cat at home! It made me smile and remember one of my favorite mantras these days, "Done, not perfect."

These are the lessons I've taken from what will be henceforth known as The Puzzle Project:

*Whether someone believes in you or not can easily sway your confidence, but in the end, faith in yourself is what will propel you forward.
*Embracing some flexibility in perspective taking can be a game-changer and support growth.
*You don't have to do it all alone - a little help from someone else can be just what you need to overcome a seemingly insurmountable hurdle.
*Creating space for creativity and play is a vital component of work-life integration.
*Release the pressure to be perfect and celebrate the good (enough).

We can do hard things! And have fun in the process.

Enjoying the Descent

I was coming down from a high of organizing and running the SDAFP symposium - it was an incredible event, if I do say so myself, bringing together almost 200 family docs for an extensive CME program that I painstakingly curated with the support of our Executive Director and Board of Directors. The energy of our community was invigorating!

Then it was right back into work the next day with some heavy emotional labor in patient care. And finally time to address some personal health issues that I had put off. Not to mention some clinic inbox issues had piled up - it was catch up time!

I was talking to my daughter as we drove up to the library after a long day. I was likely distracted by our conversation, my mental to-do list, and not to mention the emerging pain in my face after the lidocaine was wearing off from a minor derm surgery earlier that day. I cut in to the lot too early and hit the curb, busting a tire and cracking my steering column, rendering it useless and leaving us stunned. Thankfully we were safe, not hurt, and right where we were headed. I sent my daughter in to get her library books while I scheduled a tow through AAA. So many kind souls popped over to check in on me. I was pretty scattered at the time, but on reflection, I am so grateful to live in a community where people really look out for one another. And I'm so happy to have AAA and tow service within minutes at the touch of a button. And I know how lucky I am to have a flexible career where I can cancel clinic last-minute for an emergency and not worry about losing my job. I absolutely recognize the privilege I have of resources and technology so I can skate through a crisis relatively unscathed.

The next day, with my clinic schedule cleared and this unexpected gift of "free time",  I opened up a little bandwidth to understand what happened. Ater I Lyfted my kids to summer camp and made a plan with the local auto repair shop, I decided to take a mindful walk home. It involved scaling a sizable hill - I felt the burn in my legs and focused on my breathing while I huffed and puffed to the top. And when I got to the summit, I was able to pause and take in a beautiful vista of my town, framed by the Pacific Ocean, and found myself filled with a sense of peace and wonder. 

Then I got to enjoy an easy downhill trek as I descended into my neighborhood, and felt more ready to take on the many tasks at hand. It made me remember a simple truth - it is so important to challenge ourselves and stretch ourselves, but it is equally important to set aside time to replenish ourselves when we've been through some major things, so we don't get worn down.

I was so stretched and depleted, it's no wonder I put myself at risk of an accident. As my kind Lyft driver reminded me this morning, "we are not machines!" We are human beings who need to rest. I know this, I tell my patients this, I've written about this probably countless times, but sometimes I still forget to apply it to my life. Ideally we don't wait for crises to emerge to stop and take care of ourselves, but sometimes that's what has to happen to do the hard reset. And that's OK. We're fallible creatures, but we can learn and try to do better the next time. I do notice that I am better able to bounce back after mis-steps these days, leaning into self-compassion and curiosity to examine the situation with more clarity than in the past. And I'm able to access equanimity a lot more easily by finding strength through a gratitude practice when facing life's challenges. These tools have become a crucial part of my resiliency and a healthier growth mindset. 

So may we definitely climb the mountains, but may we also not forget to take time to enjoy the descent before tackling the next summit.

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.