August 20, 2021
Dear Interested Readers,
Introspection, Reflection, and Anticipation. You Think and Feel Better Outdoors
It’s been a difficult week for a lot of people. Fires continue to burn over large areas of the West even as we have become numb to the story. The Biden administration is on the verge of losing all momentum as Afghanistan descends back into medieval times. Biden’s efforts to lead us toward a more equitable society with environmental improvements are at risk as we are collectively reeling from the sudden realization that despite twenty years of effort that cost us thousands of American lives and limbs, and a huge financial investment of resources that might have been applied to domestic concerns, we are seeing a redo of the last days of Saigon. While Afghanistan descends into chaos the delta variant of COVID is filling ICUs across the inadequately vaccinated tier of southern red states. Many vaccinated people across the country are losing their confidence that the vaccine that they hoped would allow a return to normal isn’t adequate to guarantee them a COVID-free future. We can’t forget Haiti. Has there ever been a place and people who have a more distressing combination of political instability and recurrent natural disasters? Their experience of an assassination followed by an earthquake, followed by torrential rains, and flooding all within a very brief period of days suggests some sort of diabolic curse. For me, all these distressing events are punctuated by the fact that the Red Sox have done a September collapse in mid-August. Against this background, I was struggling to know what to say to you until I remembered that my most creative moments are not experienced in front of my computer. I come up with my best ideas when in the midst of turmoil and confusion I hit the road to walk or ride my bicycle. Sometimes the flash of a breakthrough idea comes as I pedal my kayak around the lake which explains today’s header.
For as long as I can remember my response to stress has been to get outdoors. As a child, if I was in trouble for having violated one of my parents’ many rules or expectations, I would hop on my bicycle and get as far away as I could. These “escapes” often became learning experiences because I would venture into some part of town I had never visited. No matter where I went I was soon feeling better and getting things into perspective which often meant coming up with an acceptable defense that justified my violation of my family’s norms or my parents’ expectations of me.
Even though I didn’t realize it at the time I now realize that what these early life adventures taught me was that I think better against the background of moving scenery. I did not realize that I was taking a deep dive into feelings as I used my body in activities outdoors and that my intuition and insights were maximized by fresh air and the beauty of nature. I did not analyze what was happening at the time. It was was just intuitive or instinctual, and the exercise always made things better, even if there was uncomfortable music to face on my return. Now many decades later I can realize that I was laying the groundwork for how I would approach all that came my way in life. The processes that I learned as a child of nine or ten have helped me through some major challenges in my adult life. Some of those challenges arose from external forces. Some I created through a life-long tendency to err. Some were combinations of both my mistakes and external events and attacks. It is now a comfort to realize that most of the outcomes of these outdoor responses to stress have been a relief at the moment, the resolution of pressing concerns, and often the awareness of previously unrealized opportunities.
As I mounted my bike last Tuesday afternoon I was experiencing a mental block. In the midst of all the confusion and disaster in the world, I was at a loss to know what to write to you about. These thoughts and the associated trip down memory lane came to my mind as I rode my bike and listened to Ezra Klein interview Anne Murphy Paul about the content and origin of her new book, THE EXTENDED MIND: The Power of Thinking Outside the Brain. [The first link is to the interview and its transcript. The second Sasan Pinker’s The New York Times review of Paul’s recently released book.]
Near the end of the review of the book Pinker writes:
…Paul writes, noting nonetheless that looking out on grassy expanses near loose clumps of trees and a source of water helps us solve problems. “Passive attention,” she writes, is “effortless: diffuse and unfocused, it floats from object to object, topic to topic. This is the kind of attention evoked by nature, with its murmuring sounds and fluid motions; psychologists working in the tradition of James call this state of mind ‘soft fascination.’”
I did not read the review while riding my bicycle along the shore of the lake, but that was what I was doing as I listened to the podcast of the interview. I was in the right space with the right past history and current experience to be an easy sell for Ms. Paul’s thesis that we think with our whole body and evolved in a world of movement. We are equipped for action and sitting at a desk or working out our ideas at a computer are not natural acts. Klein was obviously fascinated with the idea that there is more to thinking and creativity than is what is going on in our minds and he was eager to vet all of his creative quirks with this new guru. Klein says In his introduction to the conversion:
What so often feels and looks like productivity and efficiency to us are often the very activities and habits that stunt our thinking. And many of the habits and activities that look like leisure, sometimes even look like play, like if you’ve taken a walk in the middle of the day or a nap, those end up unlocking our thinking. If the question is, how can we be the most creative or come up with the most profound productive insights, you need to do that stuff.
And so if you read it correctly, in my view at least, this is a pretty radical book. It has radical implications not just for how we think about ourselves but for policy, for architecture, for our social lives, for schooling, for the economy. And I’ll say that it has stuck with me quite a bit. It has changed the way I structure a bunch of my days. I’m trying to work with my mind more and against it less.
It should be no surprise to you that Klien’s description of the drudgery of work and being non-productively chained to his computer caused me to think about the life of drudgery so many healthcare professionals experience. Others may disagree, but I think that much of the burnout in healthcare is created by the dynamic duo of slavery to the accumulation of Shou’s RVUs and the associated chains of the electronic medical record. [I have hated RVUs since they were introduced in the early 90s. I am convinced that the pursuit of RVUs distorts the practice of medicine. The link is good to explain them. I can’t find a reference, but my memory is that they were invented by a Dr. Shou at the Harvard School of Public Health as a way of fairly comparing work effort across all specialties. They were co-opted by Medicare in the early nineties as its primary payment methodology and from that platform have become the primary payment process of all of healthcare. Compensation was not the original intent of RVUs but like many problems that face us what was a good idea in one application has become an instrument for distress when co-opted and misapplied for an alternative objective. Click here for a non-pejorative discussion of the pros and cons of RVUs recently written as a practical guide to RVU compensation for doctors. It surprises me that many healthcare professionals don’t really understand the mechanisms of the payment for their services or consider the damage to themselves and patients that this methodology has perpetuated.]
As the conversation between Klein and Paul developed I appreciated her focus on how we evolved and how the typical office workplace even as it moves online and into the home or to Starbuck’s varies from how very recently our ancestors lived and worked in the world. She contends that despite the frequency with which our minds are compared to computers they are more different than similar in the way they work. Environment and feelings are a big part of what determines our productivity. Not so for computers. She answers a question from Klein by saying:
…our brain is a biological organ and an evolved organ that’s very different from a computer. And the computer metaphor for the brain has been dominant since the emergence of cognitive science in the middle of the last century, and it really permeates the way we think and talk about the brain, and it places these sort of invisible limits on how we use the brain, how we regard other people’s brains, and it’s because that metaphor is so faulty it leads us to act and to make choices in ways that are not at all optimal.
And so in this book, I wanted to challenge the metaphor of the computer and point out that, no, actually the brain evolved in particular settings, mostly outside. It evolved to do things like sense and move the body to find its way through three dimensional landscapes, to engage in encounters in small groups of people. These are the things that the brain does effortlessly, naturally. The brain is not a computer. It never was, and its failures are particular to its own nature, and it has to be understood on its own terms.
Hold up your hand if you ever thought that the practice of medicine has become dehumanizing for its workforce. Ms. Paul says that our brains are not like computers and disregarding how we were designed to work and evolved to think leads to a paradoxical reduction of productivity and not to more output. Further along in the conversation, she says that another bad metaphor about the brain is to compare it to a muscle where more exercise makes it stronger. Not so, she contends. What makes our brains work better is to put them back into an environment like the one in which they evolved. In the conversation with Klein, she applies these insights to both the office and the classroom. “Fidgeting” or restlessness while trying to work is a clue that we need to move. Some people have tremendous difficulty focusing without “fidgeting.” She suggests that children with ADHD are demonstrating their need to move to be able to learn. Knowledge workers often fidget in meetings. I once had a colleague that constantly spun a pencil or a pen as if he was a majorette in a marching band when talking to anyone. Patients and practice partners had their encounters with him as he performed his well-practiced fidget. He was a bright, empathetic, high-performing clinician whose patients loved him. I always wondered what would happen if someone demanded that he put aside his pen or pencil in a meeting or in an encounter with a patient.
Klein confessed that since the pandemic began he had conducted all of his interviews over Zoom and without the camera because he had to be walking around and fidgeting to be able to think and be engaged in the interview. Paul underlined and validated all of his observations about fidgeting and movement as actions that optimized his creative thought. The other point that she stressed was that our ideas flow from our accumulated experiences and environments. New ideas require new experiences and environments and rarely arrive in our consciousness when we are sitting at a desk or bent over our computers if we have not been “primed” by experiences before we sat down to express those thoughts.
I can report from my own experience that my insights about my patients often arrived after I left their bedside or after they left the office. The idea of a self-contained or “one and done” encounter is antithetical to good care. Good doctors usually accumulate their ideas and insights about a specific patient over time by getting to know them well through multiple encounters and then carrying observations and experiences gleaned elsewhere to the concerns that are raised. The longitudinal care process required in chronic disease management and primary care is poorly captured by RVUs. Generating RVUs does not generate joy from the practice of medicine.
Many of the observations about how our brains really work can also be applied to how we gain insights about the management of our business or the development of strategy and policy. The “aha” moment in strategy development for me was much more likely to occur on a run than in an office. One of the most productive periods of my professional life was during the mid-80s when my two cardiology partners and I regularly ran five miles together at lunchtime. We had shared insights as we ran together that we probably would never have had sitting around a conference table trying to hash out solutions to complex problems.
There is a beautiful moment in the conversation between Klein and Paul where in one concise soliloquy Paul summarized the big idea that seemed to be consistent with my personal experiences in life and especially my experiences in practice and in management:
Well, as we go through our everyday lives, there’s way more information than we can process or retain consciously. It would just completely explode our mental bandwidth. But we are taking in that information, noting regularities and patterns, and storing them in the non-conscious mind so that it can be used later when we encounter a similar situation. Then the question becomes, well, if it’s non-conscious, how do we make use of that information?
And it’s because the body lets us know. I mean, that’s what we call a gut feeling or what psychologists, what scientists call interoception, which is the perception of internal sensations that arise from within the body. And people who are more attuned to those internal signals and cues are better able to draw on that wealth of information that we know but we don’t know. We possess it, but we don’t know it explicitly or consciously. So that’s what a gut feeling is. It’s sort of your body tugging at your mental sleeve and saying, hey, you’ve been here before. You’ve had this experience before. Here’s how you responded. It worked or it didn’t work. Here’s what is the right thing to do now.
But in our world where we are so brain bound, so focused on the cerebral and the things that go on in our head, we tend to push the body aside, to quash those feelings, to override them, even, in the service of getting our mental work done, when really we should be cultivating that ability, becoming more attuned and more sensitive to it, because it has all this accumulated experience and information to share with us.
How do we incorporate these observations into the work we do? That is a long conversation. It should begin with the acceptance that what we are doing now isn’t really working well for most people. Patients don’t like the episodic care they get while looking at the back of a doctor or nurse who is squinting at a computer, and clinicians are literally dying while trying to do a job that they really believe is undoable as it is currently structured. Lean thinking teaches us that a good way to work is in groups. Improvement is often the product of activity with others. At the start of any improvement process, we go to the “Gemba,” where the work is being done and together observe what is happening. We continue by asking a series of “why” questions. When I do this with current medical practice, either alone or with others, I discover that at the end of the “whys” I come up with two insights: finance systems that undermine good practice, and a culture of practice that is reluctant to examine its “sacred cows.” Those sacred cows often obscure from our consideration those policies that are discriminatory and perpetuate inequalities among care providers and patients alike. If healthcare isn’t overtly racist, it is also not effectively antiracist. We can’t see ourselves as we are because we worship the “sacred cow” of our tremendous skills and scientific prowess.
I can’t help but think that after decades of providing patients with care that seems to be focused on finance and corporate margins rather than on patient needs, safety, and equity it should not be a surprise to us to find that some of the individuals who have been disappointed, neglected, or damaged by our care are skeptical about the core motivations of our healthcare system and are reluctant to accept our advice that they should wear masks and get vaccinated from a source that has frequently failed to live up to their expectations. The road to improvement has been an uphill struggle that had one of its first milestones, the issuance of the wisdom in Crossing the Quality Chasm in 2001 about the same time our generation-long misadventure in the Middle East began in response to the attack on 9/11. Is it possible that just as Vietnam diverted our attention from the effort to create a “Great Society,” our response to 9/11 has prevented us from having the focus to build a bridge across the “quality chasm” that we know exists? Perhaps those questions will generate ideas that I can explore with you in the future.
Returning to my childhood memories, I would report that at times I would return from my escape to the wider world and nature with a story of some unexpected adventure or observance which was often a better defense than denial since my parents were eager to see me grow and learn. I became a master at feeding them what they wanted to hear. As devious as that sounds, it was good preparation for life. A good story or an amazing observation is always a better way forward than a lame excuse or a ridiculous denial. A new direction is certainly better than a contrite and resolute submission to punishment. Punishment may be required for justice but as our penal system continuously demonstrates it rarely accomplishes what forgiveness and moving on to a new chance offers.
The last twenty months have been incredibly stressful for all of us. As I discussed in the introduction of this letter, this last week was filled with bad news and growing concerns on many fronts. I get the feeling that I think I share with many that rather than emerging from the gloom we may be going down again like a drowning swimmer who struggles to the surface once or twice before accepting the reality that the challenge to survive either exceeds their will or their strength and skill.
I have long believed that anticipation and preparation are better strategies than waiting to see what might happen with the hope that a storm might pass. Creating a strategy requires collecting as much pertinent information as possible, considering factors that may for the moment seem peripheral to the major concern, and then thinking through a variety of potential scenarios much like they were evolving stories constructed from a variety of possible responses to the question: “And then what happened?”
I think that the process of dealing with the future as an evolving story that could have various outcomes based on choices made in the plotline began for me on those “escapes” during childhood. Like Klein and Paul describe, I have used my running, walking, hiking, biking, kayaking, and solo sailing as adult extensions of that response to stress learned in childhood. As I continue to try to do these things as an aging adult I can see glimpses of hope for a better future for everyone. The key is to get out of ourselves and our individual concerns and realize that we evolved to think on the move outdoors and in the company of a community. The community today is the whole planet. If John Donne could realize over 400 years ago that “no man is an island,” that truth is even more applicable to us all now and it requires learning how to strive for equity in all aspects of life.
No one ever told me that there was not much benefit in time spent developing an excuse, but in retrospect, I can see that I have always quickly tried to extract the lessons of failure and disappointment for an event that is now history and can’t be changed and use that information to go forward with as many choices as possible to answer the question: “And then what happened?”
Be well; be a part of a larger world,
Gene
