A Culture of Self-Care

In the last several years, we hear more and more about the necessities of supporting, developing and formalizing personal plans for self-care.  Plans promoting the care of self alongside work, family, daily stressors and strains.  Plans that allow space and time to care for yourself before caring for another human being.

However, the part of the conversation that is often lost is that self-care is being solely framed as an individual responsibility.  In the medical community, movements are sweeping towards developing programs of wellness, self-care, resiliency and burnout prevention.  The problem with the momentum behind these movements, and the translatable piece to any of us in our own lives, is none of our actions occur in a vacuum.   We exist in a kaleidoscoping cultural environment. 

Personally, I have a diligent plan for my own self-care, yet I was reminded again of the surrounding environment a few weeks ago.  I stepped into our home after a challenging day at work.  I was greeted by two screaming children, and a wife stressed from her own long day at work.  Plans, structure, and well intentions go out the window in a moment like this, a moment of heightened stress.   Moments when the needs of the whole supersede the needs of the individual.  This moment reminded me, self-care relies on a cultural environment willing to embrace it.  So, I grabbed the kids and my wife took a twenty-minute timeout.  We have a parental timeout system in our house where mommy/daddy can call a timeout and leave for 20 minutes, as long as you make the official timeout gesture and a whistling sound.  Twenty minutes later, mom returns and I take a break to shower, meditate and center myself for the remainder of the day.  Having a plan to care for yourself means nothing if the culture and environment does not support its practice. 

In the professional arena, I hear cultural rumblings of self-care now being a “professional expectation and responsibility”.  Placing even more onus on the individual person.  Individuals do need to have their own plans, but if an employer does not promote, allow and/or support these practices, the efforts of the individual are thwarted by the tone-deaf bureaucracies in which our work resides.  We cannot expect self-care from individuals without also shaking the foundation of the institutions in which we work.  Self-care does not happen in a vacuum.  Self-care is not solely about personal responsibility.  Self-care is about community.  Self-care is about cultural change.

As a medical professional, the system in which I work is sick.  The system is in a moment of heightened stress.  We must build a system where it is okay to take a twenty-minute timeout.  Hand gesture and whistling sound optional. 

                                                                     - Adam B. Hill, M.D. 

THE FIRST DAY BACK

AT WORK

The first day I stepped back into work, I limped back into a daunting hall.  A hung head, a tremoring hand, and a flushed face with an encircling sense of foreboding.  I did not feel ashamed.  I was a shame. 

I spent the prior 6 weeks off work, seeking professional treatment for a self-disclosed medical condition, alcohol abuse and depression.  As a medical doctor, I made the decision to help myself before I could help anyone else.  I sought the help I desperately needed to combat the rising demons in my own life.  And it helped spark the change needed to move forward, day by day, in a journey that continues to shape the rest of my life.

In the days, weeks, months and then years after my return to work, I was a failure.  Lazy.  Unreliable.  I did not act professionally.  I was a risk.  I was weaker because of seeking treatment.  A black eye on the veil shielding the integrity of a faux ideology contrary to the tenants of the missions we all serve.  To heal those that are suffering.  Irony does not capture the sense. 

In a medical system of subspecialty based disease model of care, I am an alcoholic with a history of depression. 

In a medical system meticulous in the algorithms and pathways of treatment, I was treated.

In a medical system rooted in mortality based outcome measures of achievement, I was alive.  N = 1, 100% survival rate.   

In a medical system grounded in the merits of pharmacologic efficacy, I was responsive.  Therapeutic effect. 

In a medical system preaching the importance of early detection and interventions, I detected. Self-disclosure.           

In a medical system expecting compliance with medical recommendations, I obliged.  Compliant. 

Yet, the system told me that I was a failure. The system hung my head.  The system tremored my hand and flushed my face. The systems we have created convinced me to integrate shame into the identity of my recovery.  I should be ashamed of my own success. 

In the modern medical systems, individuals treated successfully for medical conditions are success stories.  And mental health and substance abuse conditions are medical conditions.  If we want to play by the rules outlined above, I am only a success.  You are too.  If we want to play by the rules…..well, we can’t have it both ways. 

                                                                         - Adam B. Hill, M.D. 

The Art of Empathy: A Self-Care Model

The greatest piece of advice, mentorship I ever received was very early in my professional career and it was this…..   “Don’t ever get too close to your patients”.

This is the wrong advice.  Some of the greatest mentors in my personal and professional life are those that showed me the wrong way.  I am thankful every day for this lesson. 

For those that know me, those who have heard me speak before or read any of my writings know that I live openly in medicine in having a history of depression, alcohol abuse and being successful in my own path of recovery.  Living openly this way, with a new perspective, guided me towards the light acknowledging how wrong the opening statement truly is.  The greatest strength of professional impact is the human story.  My own story, your story and finding ways to fuse stories together into a greater meaning, purpose and experience of the healer and those afflicted. 

So, today we will talk about the exploration of empathy, not only as a tool for compassionate and effective patient care, but also as an important tool in the arsenal of self-care to combat the rising tides of physician distress.   I want to challenge you to think differently, and challenge the status quo.  Common perceptions/teaching suggest to prevent compassion fatigue, a common component of distress, is to distance yourself from the work, to guard your heart and put up protective barriers.  Personally, I feel this practice is self-defeating and dangerously sets us further down the path of compassion fatigue.  The truth is, practicing empathy can be an endless, self-fulfilling well of self-care.   

Practically this requires three steps.  1) Knowing how to engage empathically in a clinical encounter 2) Reflecting and drawing out the impact of that encounter 3) Framing the impact positivity while accepting, yet minimizing the factors out of our control.  

The art of empathy.  The art of connecting to another human being.  The art of realizing the duality of the healing power of performing act of kindness, not as a mechanistic exhaust from our collectives soul, but as part of the ever filling well of rejuvenating our purpose and meaning.  

First, a few definition.  A clarification. 

Sympathy refers to an association between individuals wherein whatever affects one is seemingly familiar to another human being.  Sympathy requires intellectually comparing these two events and drawing out the similarities.  

Empathy is allowing space for understanding, awareness and sensitivity to another person’s emotions without projection and not fully knowing or understanding what is must be like to live in that person’s shoes.  

The key distinction is sympathy can be distancing, by unintentionally forcefully trying to align yourself into those person’s shoes.  “I’m really sorry your daughter is sick, I have a daughter too”. 

Empathy reflects a space willing to be present, open, vulnerable and capable of being moved by another individual while accepting that you cannot possibly know what it is really like to have the experience they are having.   “I’m really sorry your daughter is sick, I cannot imagine what this is like for you”.

The art of medicine, the art of practicing empathy is to open yourself up, to be willing to be moved, touched, inspired, challenged, afraid with your patients so that they feel you have created a space safe enough for them to do the same.  

The practical application.  I was called into the bedside of a baby in the intensive care unit, a tearful mother standing at bedside, a father with his head buried in his hands.  The prognosis given from the primary team was grim with a poor chance of survival beyond hours or days.    Before walking into that room, I clean my slate.  Relieve myself of any preconceptions, any judgements, any bias.  I have no idea what it is like to be this family, in this moment, in this time.   I consciously remind myself of that.  For us, this may be a NICU room, another consult, another Thursday.  For this patient, for this family, for this moment, it is about finding out where they are in their own journey, and sitting with them.  Some of these skills are innate, of how to be patient in the presence of suffering, but other parts can be learned and taught.  To learn the power of silence, of simple words, of kind gestures, of respect statements and an acknowledging emotions.  To provide space for tears, anger, pontifications and to let these moments organically flow. 

For those professionally struggling in this moment.  Do this.  The trick to the art of empathy is to practice these connections by drawing on your own experiences.   Think of all of the difficult moments of your own life.  Think of the heartaches, the loss, the tragedies, the deaths, the loss of a family member, or a family pet.  Collect these events and put them in a bubble, put them in a cloud.  An empathy cloud.  Consciously reflect on these events, make them palpable and salient in your mind.   Bring the sadness, anger, distance, longing and the tearful manifestations of those reflections to the surface.  And then simply do this.   Reflect to yourself - No matter how similar, none of those events are what this family is going through.  I scanned my own bubble, my own cloud of the worst moments of my life and those moments are not what this family is going through.   Sympathy scans the bubble, pulls out an experience and says “Yes. Me too. I have been there.  I lost my uncle once.  I know exactly what you are going through”.   Empathy scans the bubble, allowing for an emotional and vulnerable place with your own connections to your own emotions while then intellectually acknowledging they are different.   I am now in this space, open, tearful, vulnerable, present, raw and “I still cant imagine what this is like for you”. 

Use those experiences for good and don’t make them comparable.  Do not be naïve or arrogant enough to feel like you know what another person's experience is like. 

The second step, is to mindfully reflect on the impact of this encounter.  To assign and recognize the VALUE of being with another human being in their moments of suffering.  This is not taught, it is not even widely acknowledged.  We focus on the mechanizations and forget the truest roots of the humanity of medicine.   Healing and presence.   Relieve yourself of the arrogance that we can control outcomes.  And focus on the impact you can control.  Because when the outcomes are beyond our controls, the greatest skill, asset and contribution is compassion.  And this compassion has value, meaning and purpose beyond statistical calculation. 

Earlier this year, a teenager presented to the Intensive Care Unit (ICU) with relapsed leukemia and was diagnosed with a spreading fungal infection in his lungs.  Over the course of several days, his breathing became labored and the patient/family opted for the intervention of being on a ventilator.  Unfortunately, in the days to come, this intervention could not halt the progression of his underlying disease and this beautiful young man passed away in the hospital.  The medical teams provided every support they could for the patient, and yet, even with the best medical treatment the outcome was beyond our control.   Over the course of the week, we sat with the family, we listened to their fears, hopes, and concerns.  And in those moments of the final days and hours, we were present with them.  The intervention was presence, patience and compassion.  And it mattered deeply.  These intervention have immeasurable value.  

After this encounter, I spent time in reflection.  The second part of this empathic model requires reflecting on the impact of our interventions.  The intervention is this case was presence, patience, and compassion.  This is what the family remembers.  Not a morphine dose.  The impact, the intervention was being a human being in the presence of another human being’s suffering.   Reflecting on what was in and out of my control.  For me, accepting the mantra “There is a lot of pain and suffering in the world that I did not cause, I can only stand in the face of tragedy and try to make even a small difference”. 

The third and final part of the framework is to positivity reframe these events.  Months later, the father calls me and says “We could not have gone through that experience without you.  We will never forget that”.   Most of us that work in palliative care, and in hospice have been privileged enough to understand the value of this intervention, and I hope the rest of you will embrace these opportunities as moments of meaningful impact.  Not as mortal failings, but as moments of healing.   There is immeasurable value to these moments, and because of opening ourselves up to these moments we embrace the truest parts of our humanity in medicine.   And when you reflect, or in this case, the door was left open for a family to connect even months later, they helped to reflect the immense importance of the impact of these interventions. 

The key to this final step.  I can now place this experience as a moment in my life I was able to help another person.  This moment is not framed as a chemotherapy treatment failure.  This moment can be viewed through the lens of a profound impact of making a small difference in the face of suffering.  When you do this, it is rejuvenating.  Empathic caregiving warms the heart to know that there was a meaning and purpose to your work.  It acknowledges the value, frames the impact so that you can learn, grow and refill your cup with gratitude.  Today, I made a difference in another person’s life, even if in the midst of a devastating tragedy.  I took control of the parts of the situation I could to make a positive impact. 

These events don’t always have to exist in dramatic events on the edge of mortality, but can exist in the everyday work we do if we all continue to delve into empathic caregiving, measure the impact of our own empathy and then frame this impact as a meaningful contribution to the life of another human being.   I know that I made a difference, I can practice self-compassion with an acknowledgement of my skills and limitations, and I can be grateful for the care I have provided. 

When you delve into the fray of empathy, you walk away a changed caregiver, with a deeper sense of the purpose and meaning of the work.   And it will fill up your cup, over and over again.  Endlessly. 

                                                                               -  Adam B. Hill, M.D.

Gold Humanism Honor Society Induction Address

This society, this nomination speaks to the true heart of medicine.  Speaks to the true meaning and purpose of the work we all do.  In every office, in every hallway and every hospital ward. This society honors the patience, persistence, and perspectives of compassion.  Honors the subtle and sometimes underappreciated art of empathic caregiving and of healing.  Honors the value in the connection forged between two human lives and between two human stories.  

The truth is, all of the individuals nominated into this society have their own stories, their own journeys and their own experiences in the gifts of compassionately caring for other people.  These stories matter.  These stories matter deeply.   All of my colleagues have chosen to embrace humanity and celebrate the leveling beauty of walking with another person on their own journey – of illness, of recovery, of loss, of grief, or tragedy.   Have chosen to celebrate in the innately human story by owning true to the core identity of the calling – to heal those that are suffering.  I commend, support, admire and encourage all of this work.   The work of embracing humanity. 

I am fond of encouraging young professionals not to let medicine pilfer away their humanity.  Not to let complacency dictate to a presumed status quo.  Not to let pathways, policies or procedures rob away the soul of humanities greatest calling.  Not to let the extraordinary become routine.  The triage to become transcribed, the responses to become rote, or the rounds to become rehearsed.  The true art of empathic healing lies in a simple premise.  Do not go searching for something you already possess.  Simply hold on, cultivate and let humanity flourish in your own work, your own lives and defiantly refuse to surrender any portion of it.

It does not mean this work is easy.  In fact, it can be quite difficult.  As times goes on in all of our careers, we are all tempted to punch the clock, rehearse the lines, and distance ourselves away from the radiance of our patient’s and colleagues lived experiences.  Out of self-preservation, out of fatigue, obstacles, hoops, deadlines or expectations.  In conquering the counter-intuitive, the taught, and the developed, those that choose empathy, compassion will find a deeper meaning and purpose in the work itself.  Yet, the fear persists.  The fear of vulnerability, of exhaustion, of difficulty in finding healthy separation.   Do not be persuaded.  Be resilient in the compassion that exists in all of us because sometimes, as Marianne Williamson once said, “our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us”.

When we embrace the power of empathy, of our own compassion we can move mountains of suffering.  This light, our power changes the world – day by day in every blessed encounter.  This philosophy lays the platform for healing.  Not just for our patients but for our friends and colleagues.   When we share in the stories of our patients and colleagues we discover that we are not alone.  This transcendent message is self-sustaining and fills up our own wells of gratitude.  Allows us to discover the purpose of the work, the meaning and the impact. 

                                                                                  - Adam B. Hill, M.D.