Lose Your Fears: Part I, Fear of Failure

It has been a while since my last post and I have been quite busy back at the UVa Hospital taking part in a Transition Course as way to prepare 3^rd year medical students for rotations in the hospital. It has been  an experience so far to say the least and perhaps, most significantly, due to the fact that we have spent more time talking and working with clinical nursing students over the past week than we have in the first 2 years of school combined. While that in of itself is a problem, the reality is that now we are at least being exposed to interprofessional trainings and workshops that will ultimately reflect our true work environment.

As part of these numerous workshops and recent discussions regarding Palliative and End-of-Life Care (I just finished Atul Gawande’s book Being Mortal) and have been inspired quite passionately to pursue a proper education and exposure to palliative medicine, I have come across three major fears that we can all benefit from losing. While this may pertain and has been constructed from my experiences within the medical profession, I believe strongly that anyone can benefit from releasing his or her fear of these 3 major things. I will tackle the first fear in this blog post so stay tuned for Parts II and III.

The first and probably most debilitating fear is the fear of failure. Fear of failure is rampant in medical culture, most predominantly Dr. John Madriola and Atul Gawande write about this seemingly contradictory philosophy where in medicine, doing nothing is seen as a failure and categorized as nearly equivalent to death. Doing nothing and the process of dying can be liberating, engaging and entirely “successful” endeavors when approached from the perspective that one is actually doing the right thing. In order to fully appreciate and implement performing medical excellence, one simply has to utilize an adaptation of Atul Gawande’s five questions from Being Mortal in situations beyond just the end of life.

1. What are your goals for life?

2. What are you afraid of?

3. What are you hopes and dreams- what do you aspire to do?

4. What tradeoff’s are you willing to make in order to get there?

5. What is your idea of true happiness, or more practically, describe your ideal day?

If as a health care practitioner, you ask these five simple questions, as Gawande notes, the correct path towards achieving the patient’s identified goals often becomes quite obvious. With the individual invested into the process of hopefully achieving his or her desired health outcome, there is essentially almost no way one can judge this as a failure.

Need an example? Let’s take our average 65 year-old recently retired male with CAD, HTN, DM II who is overweight, doesn’t exercise, lives a predominantly sedentary lifestyle and eats a SAD inflammatory diet. Traditional medicine would call this man a failure is he: 1. Dies of a CVD event or from CVD related complications, 2. Does not maintain a HgbA1c below 6.5% 3. Does not maintain a blood pressure below 140/90 4. Does not maintain an adequate lipid panel- best practice should utilize a TG/HDL <3. 5. Imposes an undue, chronic burden on the healthcare system in relation to financial and social welfare.

Now, while I totally agree that a chronically sick American population is certainly the most harmful issue facing our overall social welfare, the brutal reality is that this collective is made up of individual “failures” within the traditional system and only by addressing the individual can we eventually hope to improve the whole.

So let’s apply our 5 questions and see how we can avoid practicing medicine from the fear of failure, and empower the patient to see that indeed there are other metrics to use when it comes to assessing successful medical care.

What if this person’s hopes and dreams are to simply be alive to see his grandkids grow up; What if his biggest fear is dying from a MI without being able to say goodbye to his family; What if his primary goal is to spend time writing poetry and short stories now that he has finally retired; What if he is willing to adopt some minor changes to his lifestyle and diet while routinely seeing a doctor to assess metabolic markers of health; What if his idea of the perfect day is sitting on his porch, watching the sunset with his grandkids on his lap, telling stories of how he used to be the fastest runner in his high school?  Do you see that all of those metrics of success or failure we identified in the traditional medical system neither provide a direction for improvement nor a meaningful framework in order to help this man?

So from this understanding what could a plan for improvement be:

1). Assess current medications and optimize blood pressure control, lipid levels, blood sugar and inflammation in order to stabilize his levels- notice that this does not involve adding new medications, enforcing an expectation for these markers to be lower or improved and, if anything, should involve removing medications to relieve any potential unwanted side effects he is currently experiencing.

2). Find out how he is currently spending his time, where does his family live, who are his social supports, is he satisfied with the time he is spending with his friends and family, what are the barriers to achieving his goals for being with his closest loved ones

3). What are his major hobbies, what does a typical day look like, how much time does he spend pursuing his writing, is he willing to adopt an equal amount of movement, walking, house chores for time spent writing? Does he utilize any technology on a normal basis?

4). Is he willing to modify his diet by adding more fibrous vegetables, eliminating a majority of processed and packaged food and simply spending more time cooking and preparing real food meals? Is he willing to follow-up with the medical team with his dietary progress by tracking meals, body weight and overall happiness during this transition? Can he commit to seeing/communicating with a physician on a regular basis to aid in his journey?

5). Most importantly how can the medical staff be of the most use to him? What practically would provide the best support for the patient? What does he see as reasonable goals for weight loss, activity, engagement with his family? How can we minimally disrupt his life in order to provide the best quality of life possible?

So we can see, there is so much beyond practicing in a world full of the fear of failure, from the abnormal lipid, blood sugar and blood pressure values, to the lack of adherence to a strict dietary protocol, to an inability to take all prescribed medications, to complete ineptitude in engaging in the necessary exercise regimen. As a medical student, I have lived this world, lived with this fear of failing, of innumerable expectations, felt the embarrassment of being unknowledgeable and seemingly unworthy of the task. Instead of thinking, why am I not capable of achieving an outcome, we should be asking is the desired outcome really what I should be striving to achieve?

Learning, Motivation, and Praise: How Do We Learn Best? Part III

           For the final Part of my three part series Learning, Motivation and Praise: How Do We Learn Best? it is time to put our “Growth Mindset” and our newfound resilience to practical use. So far, I have primarily focused on the external aspects that can affect how we learn such as the impact of outside praise as well as environmental challenges and obstacles, all the while only alluding to the fact that we do have the personal power to construct our response to such obstacles. The problem occurs, however, when we do not act with proper mindful awareness, and subsequently default to operating without a real internal locus of control. In the end, we want to be able to achieve and succeed in our academic and life pursuits without the reliance of others providing meaningful praise/actionable criticism, or simply dumb luck by avoiding the wrong set of circumstances that overwhelm our capacity to cope. How do we do this? The answer is rather simple and it comes from one of the greatest masters of learning: Josh Waitzkin.

            In the second podcast conducted by Tim Ferris, which is becoming a rather compelling collection of interviews combining alcohol, dinner conversation, and absurd yet cerebral questions with some of the greatest minds on the face of the Earth, Josh Waitzkin provided some of the deepest and most practical advice for productive and successful living.

Listen Here: http://fourhourworkweek.com/2014/04/22/tim-ferriss-podcast/

            If I could boil this amazing interview down into 2 poignant insights from Waitzkin, it would be this. First, Cultivate Space in Your Life. We are all consumed with how to be the most productive and efficient human beings, combining work, academics, social and family life as well as parenting into some semblance of organization that we can all too easily forget about the essential reality that we need space, pause and transition. Actively dedicate space and time in your life to not just “nothing”, but to personal exploration. Waitzkin advises us to deconstruct and “subtract” extraneous material in our lives in an effort not to become more efficient, but to allow ourselves to function without constantly impeding our progress as knowledge seeking human beings.

              The second practical point tells us how we can choose to spend time within this cultivated space of self awareness: Nurture Your Creativity. Whether you actually use this space to creatively think and express your being through whatever art form, or allow this time for meditation and restoration such that you can enhance your performance in other aspects of your life, we all must take a proactive effort in treating our creative minds as sacred, nourishing this flame of being with constant vigilance. I can attest to the fact that we are often our own worst enemies when it comes to sabotaging our ability to creatively think, and ultimately, live on a hamster wheel of unmet expectations.

            By following these words of wisdom: “Cultivate Space in Your Life” and “Nurture Your Creativity” one can practically make the most of a resilient “Growth Mindset” The truth is, most of us suffer from not only a complete lack of either resilience or a “Growth Mindset,” but an inability to successful practice these principles without real life guidance. Upon entering medical school, I certainly did not have a robust resilient spirit, and even my positive attitude and “Growth Mindset” could not overcome the fact that I was by no means seeking to cultivate space in my busy life, and eventually came to subtract the very activities that actually allowed me to think creatively, spontaneously, and free from the world of medicine. Life is a process of continuous learning and adaptation, and without adversity we will never realize our true potential for resiliency. I hope this series was informative as well as entertaining. May we all aspire to live as resilient humans seeking achievement, happiness, self-worth and a legacy worth leaving.

Learning, Motivation and Praise: How Do We Truly Learn Best? Part II

            In Part I of this blog series, I described the idea of a “Growth Mindset” as postulated from the work of Carol Dweck with hundreds of hardworking school aged children. Her research now supports the idea held by thousands of lifestyle coaches, gurus, and self-help books, all touting the hidden potential of simply questioning when, not if, one will accomplish a given goal. As I mentioned before, I am a pragmatic realist to be redundantly redundant, but the truth of the matter is that nearly everyone will improve with some degree of encouragement, praise and handholding. Medical research is rife with studies examining the placebo effect or to some degree, the effect of an intervention due almost entirely to establishing a positive, engaging relationship between a doctor and a patient, or a health care team and a study subject. No one will deny this fact, but many will be quick to disregard this effect as insignificant or rather irrelevant to the overall efficacy of the treatment being examined- examples include a drug, surgery or psychological intervention. But rather than question and spend millions of dollars researching various drugs and interventions to find some minor improvement in treatment outcomes, why can’t we attack the problem from a different angle, how can we enhance and augment the placebo effect as well as what I call “The Human Love and Attention Effect.” Instead of trying to fix the nearly irreparable health care system, why not just operate within its confines, but play by different rules. This is precisely what Carol Dweck decided to do when she entered the classrooms of underperforming children in an American education system in desperate need of an overhaul. Her solution: don’t try and change the curriculum, simply empower the kids to think and be challenged, for success shouldn’t be judged by A’s on the report card, but by the willingness of a child to pursue knowledge.

            Now having set the stage for what we hope to accomplish through our “Growth Mindset,” the question now becomes how do we cultivate this environment for optimal results? This is where work by Ashley Merryman and Po Bronson in conjunction with Dweck’s research appears to become so valuable.  In their landmark NY magazine article “The Inverse Power of Praise” Merryman and Bronson outlined the prominent findings of Dweck’s research studies, students who were praised for their “intelligence” rather than for their “effort” on a given test or task were subsequently less likely to later chose to engage in a more challenging and rigorous assessment, while those praised for their “effort” were seemingly very willing to try something new that they were told would be more challenging than their previous task. In addition, after giving both sets of students a purposefully challenging task to induce failure, Dweck found that when the children were subsequently retested with the initial task, those praised for their effort showed a marked improvement- near 30% on their scores, while those praised for their smarts actually performed worse by nearly 20%. This finding was astonishing considering the students all acted as their own controls from test to test and were merely responding to researcher feedback. It is hard to argue that in this study, the children praised for their smarts were significantly less resilient in the face of a challenge, so much so, that they performed worse on a previously easy task. So it appears that encouraging a “Growth Mindset” as well crafting resilient human beings is the key to ultimately continuing successful academic pursuits. As Merryman and Bronson point out, the path to success is paved with actionable and sincere praise, if we are simply told that getting an A or lowering someone’s Hgb A1c to a certain level is successful, than it is not surprising that kids will cheat and doctors will overmedicate and treat to get to this goal. By subtly changing the language that we use to encourage and empower our youth or when it comes to health care, our patients, we can likely see dramatic improvements even within a broken system.

            While I could go on about the fascinating findings of Merryman in regards to test-taking environments, academic competition and crowd mentality, I want to end this post with an n=1 acknowledgement of what I have described above. I can personally attest to being a product of tremendous hard work and dedication to get to my current place as a medical school student. I distinctly remember being told repeatedly how smart I was or how amazing my grades were, or how seemingly easy I made some work appear. For me, however, this praise was really only fuel telling me that all of my hard work and productive effort was providing the results desired by my teachers and peers. By the sixth grade, my parents along with my brother and I, decided we didn’t want our grades publically shown in the class honor roll, as we believed, for one, that this was personal, and two, that these results were not necessarily indicative of hard work or creative thinking. Deep down I knew that I was certainly intelligent and coming from a family full of academics with more PhD’s than I can count, I probably have some good genes, if there is such a thing for natural intelligence. In the end, however, I knew that in order to achieve the goals I had set for myself, I would have to work harder than some and my “more gifted” peers. While I can whole heartedly say that I became a persistent and determined student, it wasn’t until my first months of Medical School that I realized I was missing one real key ingredient: true resilience. While I certainly showed elements of this throughout my academic pursuits, I had never ultimately been challenged to the extent that I required dedicated cultivation of a resilient spirit. Put another way, I didn’t realize what it meant to be truly resilient, physically, mentally, and most important spiritually. It is not sufficient to simply have the will-power and work ethic to pursue your goals, one must actively cultivate resilience in all aspects of one’s life in order to find true happiness. This is how we must educate our youth, empower them to think creatively, praise them for their efforts in the academic process, and build resiliency in the face of mental, physical, social, and emotional stress. I wish I could have taken Resiliency 101 instead of Introduction to Microeconomics, but alas this course did not exist. Hopefully, someday we will construct an education and health care system that will promote both the “Growth Mindset” as well as the “Resilient and Compassionate Human Being,” but for now, we can try to operate within “Straight A” and “Stoic” frameworks of these systems by changing our language for praise, changing our self awareness and opening up to the idea that we don’t always have the answers.

Part III