Over the rainbow

“Someday I wish upon a star, wake up where the clouds are far behind me, where trouble melts like lemon drops, high above the chimney top, that's where you'll find me.” - Harold Arlen & Yip Arburg

I’ve longed believed that 90% of health is mental health, so I’m really glad that that this week’s North Valley leadership communications focused on our emotional wellbeing. I hope that you will take advantage of at least one of the many resources we have made available to help you get more settled. We’re embarking on a three day Memorial Holiday weekend. In addition to creating space for us to honor and mourn members of the military who have died while serving our country, this weekend gives us the opportunity to slow down and reconnect with our thoughts and emotions. I encourage you make a solid connection with your sense of optimism and hope for a better tomorrow. To get you started, please enjoy this Davis High School Madrigals performance of “Over the Rainbow” sent to me by Kathy Eastham, Pediatrics.

Lessons from a fighter pilot

I know a young man who is a US Navy fighter pilot. He’s an elite aviator who engages in high stakes work, under imperfect conditions, at great risk to his personal safety. Sound familiar? I asked him to share some cockpit wisdom that might be helpful for us as we engage our enemy, the COVID-19 pandemic. These are his cockpit pearls (followed by my comments in italics):

“No fast hands in the cockpit.” A misconception in the public is that the best fighter pilots must be those with lighting fast reflexes. However, in reality, our training emphasizes just the opposite. During an inflight emergency, when the Master Caution light is flashing in your face, the urge to impulsively flip a switch or activate a back-up system can be overwhelming. It is during these moments that we fall back on our training, find the checklist that is the best fit for the scenario, and execute with deliberate focus. When things get ugly, take a deep breath, and fall back on your training. Stick to the fundamentals. The 4-P’s mantra comes to mind: “Keep them puffing, pumping, perfusing, and peeing.”

“Bounce Back.” Fighter pilots make mistakes all the time. Whether in dynamic training exercises or in actual combat, there is no shortage of threats that hinder perfect execution. The best among us are those who are able to acknowledge the mistake, mentally compartmentalize the error for the debrief, and continue the mission with a focus on all the other opportunities left to succeed on that sortie. Rapid sequential tasking interrupted by generous self-affirmation is what our patients need from us.

“Show of Force.” Unfortunately, in combat, the enemy gets a vote. This reality can produce moments of intense frustration when the circumstances of the engagement feel dictated by the adversary. In a tactical jet circling overhead as a chaotic ambush below unfolds, our most requested response is a “Show of Force.” This maneuver calls for an extremely low, fast, and loud pass over the engagement and is intended to display to the enemy what a poor decision they just made. Although the desired response is a retreating enemy, often the feedback we receive is that of the uplifting effect the maneuver had on our friendly forces during their time of need. There is no greater show of force than our dedicated teams of health care professionals bringing their best to the fore as we fight the battle of our lives.

The one thing

The topic of yesterday evening’s weekly North Valley Town Hall meeting was Workforce Wellness. The faculty included leaders from psychiatry, human resources, physician wellbeing, and the employee assistance program. It was my pleasure to represent physician health and wellness. During Q&A, a listener asked me to identify the one wellness practice that I have observed to be effective during the entirety of my thirty-one year career with TPMG. My immediate answer was CONNECTION. Why connection? John Travis, the founder of the modern wellness movement, said that “the currency of wellness is connection.” I like to say that “connection is the coin of the realm in the kingdom of wellness.” Connection to what? The answer to that lies in the writings of Dr. Richard Swenson in his book, Restoring Margin to Overloaded Lives.

Connection to other people = your social life. During my first year of work with TPMG in 1989, I was doing weekend rounds on an elderly gentleman on the hospice service. After I completed my bedside evaluation, he asked permission to give me some advice. Of course I said yes. I was a 29 year old newly minted family physician who didn’t know much about anything. He leaned in and said, “Young man, I just want to let you know that at the end of your life, all you really have are the relationships you developed with other people.” His words immediately struck me as pure gold. He died a few days later, but his wisdom lives on, today in this email.

Connection to yourself, your purpose for living, and the story you tell yourself about you = your emotional life. This emotional life is in many ways the most complicated one. I encourage you to consider meeting with a counselor to make sure you get it right.

Connection to God or a mighty transcendent being or idea = your spiritual life. For many people, this is the one abiding life, the one that unifies all elements of life.

To appreciate the importance of connection to wellness, consider the consequences of life without connection: isolation, loneliness, simmering in destructive stories about the self and others, wandering with no purpose or direction, the futile pursuit of happiness based on things and circumstances. You get the picture.

In summary, there is consolation in community, and desolation in isolation. The choice is yours. Make a good choice. If you need help doing this, please reach out to a wise person that you trust. It might be a licensed counselor, a religious leader, or your favorite relative. It might also be a patient who has been through a lot, and in doing so, has learned something important that he/she is eager to share, much like the hospice patient who intentionally connected with me in the sunset of his life.

The making of a miracle

“The only place where success comes before work is the dictionary.” - Vidal Sassoon

We all love miracles. The curing of leukemia, the birth of a healthy baby after prolonged infertility, the ending of a pandemic. In sports, one of my favorite miracles was “The Catch,” Dwight Clark’s leaping touchdown reception of a Joe Montana pass in the 1981 season’s National Football Conference championship game between the perennial powerhouse Dallas Cowboys and the upstart San Francisco 49ers. Trailing 27-21 with 58 seconds left in the game, the 49ers faced a third down and three on the Cowboy’s six yard line. Joe Montana took the snap from center and rolled to his right looking for his primary receiver, Freddie Solomon. Solomon slipped while running his route, forcing Montana to scramble to elude the rush of three oncoming Cowboys, including 6’8” Ed “Too Tall” Jones. A split second before being forced out of bounds, Montana lofted a pass to the deep right corner of the endzone, where Clark leaped above defender Emerson Walls to catch the ball with his fingertips and send the 49ers to the Super Bowl, where they would win their first of five Super Bowls over a thirteen year period. What many people forget about “The Catch” is that it was preceded by a dramatic thirteen play drive that began for the 49ers on their own 11 yard line with 4:54 left in the game. “The Drive” included four Montana pass completions, four runs totaling thirty yards by Lenvil Elliot, and an end-around run by Solomon good for fourteen yards. Just as we remember “The Catch” as being the play that defined the end of the Cowboy’s reign and beginning of the 49ers dynasty, I suspect that historians will attribute the end of this pandemic to a vaccine or drug. However, when we eventually get to the other end of this virus infested tunnel, we should record for posterity that we would not have survived this disease without the people who sheltered in place, the engineers who kept the lights on and sewage flowing, the essential workers who kept us fed, and the many members of the healthcare team who left their homes and families to tend to the sick. They, we, are the unsung Lenvil Elliots and Freddie Solomons, without whom there would be no civilization left for a vaccine or drug to save.

Take yourself to a happy place

Feeling cooped up by the shelter in place restrictions and the cancellation of your vacations? Me too. But rather than be a helpless victim of a tiny coronavirus, I choose to leverage my mindfulness and guided imagery training to regularly take myself to happy places throughout the world, not in the typical bodily sense, but in my mind. It works like this. I put on my Rainbow brand sandals that are a constant companion wherever I go. My dear friend and wellness colleague, Richele Thornburg, Executive VP, People and Leadership Strategy, The Permanente Federation, reminds me that the correct name for this luxurious footwear is “slippas.” Of course, my slippas call for me to accessorize with a comfortable well-worn t-shirt, shorts, and a wide brimmed hat for UV protection, or a farmers cap if I am feeling young, hip, and unafraid of skin cancer. I then set out on a walk in my neighborhood (pictured below, bottom row, center). But instead of mindfully appreciating my immediate surroundings, I take myself to one of my happiest places in the world. That place would be Hawaii, a cluster of tropical islands where I am filled with peace and joy with no effort. In an instant, my stress and worries melt away and I am connected to the tastes and textures of savory Spam musubi and sweet shave ice, the 82 degree 55% humidity weather that forces me to slow down and mellow out, the sensation of weightlessness experienced while floating in warm ocean water surrounded by friendly tropical fish, and the hospitality of my island hosts who thrive on making me feel welcomed and cared for. Where is your happy place? Since you probably can’t drive or fly there at the present time, why not take a virtual visit in your mind? Slippas are optional, but highly recommended.

Pandemic PSAs from Jimmy Fallon and Friends

Nothing stirs, inspires and calms the soul like music. And some of the best music during pandemic times is found in collaborative virtual remixes of classics whose messages describe our current angst and admonitions. Melissa Arca, Pediatrics, shares this Jimmy Fallon, Brendon Urie, and The Roots remix of “Under Pressure,” a recognition of the intense stress we are feeling from all angles. And from Stacey Bowman, Pediatrics, a Jimmy Fallon, Sting, and The Roots remix of “Don’t Stand So Close to Me,” a rousing reminder that a fundamental element of surge containment is physical distancing.

Training our brains to be Velcro for the good

"It's time to rewrite the maxim that practice makes perfect. The truth is, practice makes myelin, and myelin makes perfect.” - Daniel Coyle

Have you ever found yourself feeling stuck in your quest to become more emotionally resilient because of a tendency to focus on the negative? Where does that come from and how can you retrain your brain to focus more on the positive? The answer is summarized well in this Inc. article by Susan Steinbrecher that features the work of Rick Hanson from UC Berkeley’s Greater Good Science Center. “The brain is hardwired to focus on the negative. It is a phenomenon that social scientists have labeled as the ‘negativity bias.’ It refers to the innate ability to absorb and anchor negative events and thoughts, and to bypass or give less attention to the positive ones. Simply put, the brain is built with a greater sensitivity to focus on bad news. As Hanson puts it, our brain is ‘like Velcro for the bad experiences, and Teflon for the good ones.’ The negativity bias is the result of the way in which our ancestors' nervous systems evolved, millions of years ago. While they hunted for food and avoided predators their brains were constantly on defense mode -- planning for the worst case scenario, in order to survive.” I’ve heard this tendency for our primitive survival-mode brain to be Velcro for the bad described as “frog brain.” The good news is that we can rewire our brains to be stickier for good news. The path to this enlightened brain starts with mindfully looking for positive situations in our lives: one more day of good health, clean water, electricity at the flip of a switch, a refrigerator, food in that refrigerator, a thank you from a patient, a colleague who replies to your Cortext question, a nurse who dresses your patient’s wound, a custodial worker who keeps your office tidy . . . the list goes on and on. It’s equally important to let the good feelings associated with these positive situations sink in. According to Hanson, this drives the process of installation into your nervous system, essentially rewiring your brain = neuroplasticity. Like the formation of any other adaptive habit, looking for the good requires intention and practice. But oh, the places you’ll go in your life with a brain wired to be Velcro for the good!

You'll never walk alone

“Hope is the thing with feathers, that perches in the soul, and sings the tune without the words, and never stops at all.” - Emily Dickinson

We’re a few months into this pandemic, and we are settling into a new type of funk. At work, the early commotion has subsided, surge mitigation is on autopilot, and surge preparation is mostly parked, with the notable exception of procuring PPE. Our new challenge is figuring out how to address the work that is piling up. At home, we’ve made the best of having the kids around by coaching them through their virtual lessons, being grateful for the extra family time, and pretending this is a staycation. But enough is enough. Kids were meant to be at school and hanging out with friends. And while many of us are more physically active than before shelter-in-place, walking, biking, and virtual yoga are getting stale. We yearn to exercise with people, pass balls back and forth, and share sweat and heavy breathing without worrying about contracting a fatal disease. We are also filled with survivor’s guilt. While others in the world are losing their jobs, getting sick, and dying, we complain about our work being inefficient, the inability to see and hug our elderly parents, and cancelled vacations and graduation celebrations. How can we live with our unpleasant pandemic feelings, especially when the duration of the funk is unknown? First, know that you are not alone. Most people in the world feel the same way, and there is consolation to be found in a community of shared grief. Second, there is hope for a better tomorrow. That hope lies in a continued commitment to flatten the curve, disease tracking, development of an effective vaccine, and the power of human to human transmission of encouragement and hope. Nancy Rozance, wife of retired Sacramento PIC Jack Rozance, offers us the latter in this virtual rendition of “You’ll Never Walk Alone” from the Rodgers and Hammerstein musical, Carousel. Feel a lift of wind beneath your wings as 300 people from 15 different countries come together to remind us that if you have hope in your heart, you’ll never walk alone. #FightTheFunk #KeepHopeAlive

Profiles in courage

Several years before he was elected President of the United States, John F. Kennedy wrote Profiles in Courage, a collection of biographies about eight US Senators who demonstrated great bravery and integrity while doing work they believed to be essential to the preservation of our Union. There have been many such stories of courage among our present and former colleagues over the past two months. Early in the COVID-19 pandemic, when fear was plentiful and facts were few, an email was sent to a subset of departments in the North Valley inviting physicians to be trained for work with the ER and HBS teams in the event of a surge. A small group of volunteers signed up at a time when there was a legitimate concern that Kaiser Permanente would face an onslaught of critically ill COVID-19 patients similar to what was seen in Wuhan, Italy, and New York. Alyn Kelley, AFM, and Wenny Jean, AFM were part of the first wave of redeployed physicians. Wenny recently sent this report along with the photo seen below: “This is my awesome Roseville Medical Center HBS Surge training team. Alyn and I shadowed our HBS team leader, Shafia Khan, the first day and were then were assigned an increased load throughout the week. I carried three complex patients, rounded daily, and discharged one patient today. I felt the care we delivered was really second to none and I am so proud of being a Permanente physician and part of this strong team. I am grateful for Kaiser Permanente and this opportunity to contribute in some small way to this bigger global pandemic.” Demonstrating a similar “can do” spirit, a group of retired TPMG colleagues that includes Pete Oftedahl, Jeff Dubois, Katie Rutherford, and Charlie Moore all volunteered to staff the COVID-19 field hospital at Sleep Train Arena. Reports Pete, “While this was in the planning stages, the California department of health sent messages to health care providers in the state asking for volunteers for the California Health Corps (CHC) - to serve as doctors, nurses, respiratory therapists, pharmacists, EMT's at these facilities. They also asked whether you might be willing to go out of state - if another state's needs exceeded ours. 80,000 responded. In our area we wound up getting about 35 physicians interested, but when we started on April 17, there were only 27 and now we're down to just 12.” Click here for more details from Pete and Jeff about their Sleep Train experience and ongoing desire to be of service to others following their retirement from TPMG.

Games

From Mayuri Desai, pathology, and Redwood City wellness leader: For the past several weeks, my family of four has been playing a board game every night after dinner. My son, a first year law school student is in the middle of finals right now. My daughter, a senior in high school is preparing for her AP exams and finals. Despite their academic schedule, we have found that spending time playing a board game has many benefits for each of us and for our family as a whole. It is establishing a routine that we all look forward to each day. The winner decides which game to play the next day. As you can see from the photo, our favorite games have stayed out on our table for the past several weeks. The others are still in the closet, but they come out from time to time. We have found that playing Apples to Apples, Whoonu, Sorry, etc is still fun even though the kids have grown up now. Since your family likes Ticket to ride, I have to say that we have played USA, Europe, India and Switzerland and just added Rails and Sails to our collection last week. Even though they are all Ticket to ride, they have some differences so it does not appear that you are playing the same game. You will like Codenames and Decrypto too. Also, we learned that certain games like Catan, Codenames, etc could be played with family and friends virtually through their website. Physician Health & Wellness was organizing board game night for Redwood City and San Mateo physicians and families every other month in the past and it has been a great success. I am waiting for shelter in place to be lifted to start offering that again. If you have not been to Games of Berkeley, you should check it out when they open up again. They have a really large collection of games and several game rooms. You can drop by to play any game, that way you get to try out different games.   

A sense of coherence

In his book Switch: How to Change Things When Change is Hard, Chip Heath points out that whenever human beings are faced with great challenges, there are some people and groups that stand out as “bright spots” of exceptional innovation and adaptation. During this pandemic, I have seen many bright spots bring light to the darkness. Li WenLiang, Anthony Fauci, my AFM team leader Kris Kordana, and Kaiser Permanente come to mind. But have you ever wondered how these bright spots manage to rise above their own fear and despair, maintain positive attitudes, and make progress amid chaos and uncertainty? Me too. Part of the answer lies in the study of salutogenesis (the origins of wellness; as opposed to pathogenesis, the origins of disease) and the research findings of Israeli sociologist Aaron Antonovsky. Professor Antonovsky was particularly interested in how some women survivors of great hardship, specifically the death camps of World War II, emerged from the depths of their suffering believing that life was good and that their lives had meaning. Why didn’t their horrific experiences destroy their spirit, or at the very least, leave them as hollow women whose lives ended with a whimper? Antonovsky argued that their grit was based on their “sense of coherence” (SOC), a three part disposition that dictates how one reacts to circumstances.

I like Hirsch, Lazar, & Braun-Lewensohn’s 2015 description of the three elements of SOC:

• Comprehensibility is the ability to see the world and life events as understandable, ordered, and to some extent, predictable
• Manageability signifies one’s confidence that he/she has the necessary resources to deal with environmental demands successfully
• Meaningfulness indicates the belief that life is worthwhile and that its challenges are worthy of the investment of effort and resources. 

The good news for physicians is that we are already deeply rooted in the three pillars of SOC.

• We were the idealistic teens who thought that we could harness our energy and talents to effect positive change in a chaotic adult world ruled largely by entropy.
• We were the dreamers who had the confidence to believe that we would survive the rigors of the premed grind and gain admission to medical school.
• We were the courageous medical students and residents who drew on our newly acquired book knowledge, shiny new stethoscopes, and Scut Monkey handbooks to see one, do one, then teach one for the sickest patients tertiary academic medical centers could throw at us.
• And today we are the healers who find meaning in dedicating our lives to the important work of caring for our patients and the communities we serve.

COVID0-19 is a formidable foe, a worldwide pandemic for the ages. Our profession is well positioned to adapt to this event with a unified sense of coherence that is based on our proven ability to comprehend and manage great challenges and our shared belief that life is absolutely worth fighting for. As physicians, we have a responsibility to let our SOC shine and bring light to those around us.  #BeABrightSpot

Free birds will make you melt

I’m not talking about the popular Freebird women’s leather footwear, but rather free access to beautiful bird pictures and videos brought to you by the Audubon Society. Hillary Campbell, AFM, shared this site with Ruth Ann Bertsch, HBS, who in turn shared it with me. This is an example of the positive ripple effect, in this case, shared by three people who go way back, as I had the honor of hiring both Hillary and Ruth Ann during my previous life as the AFM and HBS recruiter for the North Valley. Gushes Ruth Ann, “The series (multiple) about parents and their babies are the best! After looking at ten, my shoulders palpably melt.” #freebirds #meltaway 

No importante

“Life is about perspective and how you look at something... ultimately, you have to zoom out.” - Whitney Wolfe Herd

From Denise McNamara, chief of psychiatry, Santa Clara, this insightful and humorous original poem about what’s important, and what’s no importante, as seen through the lens of a human being immersed in a pandemic.

Good job

From Rakhshi Khan, AFM and mindfulness leader: Alicia Keys blesses us with this newly released ballad titled, “Good Job.” She wrote it last year as a tribute to the unseen and unsung heroes in her life and beyond. The lyrics “Don’t get too down, the world needs you now, know that you matter” are a fitting tribute to the many people today who are continuing to do their work for the benefit of others, often times at great risk to themselves and their families. Said Keys, “Whether you are on the front lines at the hospitals, balancing work, family, and homeschool teaching, delivering mail, packages, or food, or facing other personal difficulties because of COVID-19, I feel you. You are seen, loved, and appreciated.”

Flattening the curve, Taiwan style

Taiwan, a country of 23 million people, is only 110 miles across the Formosa Strait from Mainland China. Yet, its numbers of COVID-19 cases and deaths have been relatively low. Could it be because their Vice-President, Chen Chien-Jen, earned a Doctor of Science in epidemiology from Johns Hopkins in 1982, and early in the pandemic rolled out a comprehensive nationwide plan to flatten its curve? No doubt that helped. You can click here for details. But a sound strategy alone would have been insufficient if the people of Taiwan did not follow their leaders and embrace the physical distancing and masking practices demonstrated in this video sent to us by the 83 year-old grandmother of Thomas Lee, emergency medicine. My conclusion after watching both videos is that an effective strategy for meeting the challenge of COVID-19 goes something like this:  combine good science with strong leadership, front-line adoption of practices that reduce transmission, and generous doses of good humor and positive thinking.  #WeAllNeedHaircuts

Art for the heroes

Anvita Gattani, the daughter of Monika Gattani, HBS, has started an #ArtForTheHeroes project to recognize essential worker heroes for the contribution they are making to our society. She will be featuring seven artists per week for the duration of the pandemic. The goal of the contributors is to encourage, uplift, relax, and inspire togetherness during tough times. Click here for a collection of her productions to date. Enjoy!

Power of compassion meditation session

From Mamatha Gupta, AFM, a heads up about a free mindfulness webinar hosted by the Heartfulness Institute. It is scheduled for Saturday, May 2nd at 8am PST. Mamatha has done the heartfulness meditation and it helps her to reduce her stress and feel more calm. I’m thinking that many of us could use more calm. Click here to register.