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Submitted February 2025
by Richard DeBehnke, MD
Medicine’s True Work: Building Trust
As I prepared to step away from the active practice of medicine, I was asked to provide some perspective on my journey. Ask my family, my peers, and my patients and they will confirm that I am more than willing to share.
Perspective tells me that we are not in the business of diagnosis, treatment, or procedures but that we are in the business of trust.
This is curious to me because my medical training never emphasized trust. It was my experience that the opposite was encouraged: C.Y.A. Instead, the emphasis seemed to be on ordering an excess of labs, never admitting a mistake, and in general doing anything and everything to avoid malpractice claims. Our patients were known as “heart failure in room 207,” effectively reducing someone’s loved one to an ICD 10 code. But we were smart, we were committed, and we took care of people.
As my career progressed, I struggled with finding the most efficient way to persuade patients that a course of treatment was necessary, reassure them while they were suffering, and help them accept the reality of their illnesses. How could one best take their knowledge and skills and do some good? In day-to-day practice how do you find success and reward in what you do?
I do not have answers, but it seems obvious to me that trust is involved. Without it, medical care seems impossible. Miraculously, trust seems to exist, but where did it come from and what did I do to deserve it from my patients?
How do you get someone to trust you?
Hemingway was quoted as saying, “The best way to find out if you can trust someone, is to trust them.” It is humbling to realize the people that step into our exam rooms do just that. They take a chance on us. How did we earn this generous gift? By being right all the time, curing every illness, or performing procedures no one else could do? We know this is not what happens. What are the step-by-step directions to acquire this ability, the conscious changes to make, or the places to go to uncover these mysteries? Can any of us say when it happened? Was it always there?
The other side of this beautiful dynamic, which rewards us as much or more than it does our patients, asks: If we are trustworthy, are we trusting? If our patients have the traits of a trusting person such as reliability, patience, openness, vulnerability, and honesty, do we share the same traits? Are we as open and vulnerable with them as they are with us? Can we really care for anyone without making that connection of trust, letting them know that not all of our experience comes from textbooks or seminars, but from walking the same paths that they have? Are they really just looking for a partner to walk the road with them, guiding them around most (but not all) pitfalls, and being there to help them up when they stumble? From these fellow travelers we receive the thanks, loyalty, and respect that make our work meaningful. Reflecting on all the books we have read and shows we have seen, haven’t we sat in rooms and heard real stories just as dramatic and poignant? “Can you help me?” may be the highest praise one person can give to another.
I believe what is most important to the people we care for is not getting it right but getting them.
Finishing this I am struck by the number of questions I have asked, so obviously this is not a guide or set of instructions. But I am confident in saying that we are purveyors of trust, and I encourage you to open up and trust your patients, your peers, and most importantly, yourselves. Perhaps all this is just a personal reflection on my career. If so, I hope reflection implies that a little light and some focus has been generated along the way. That would be good enough.
Dr. Richard DeBehnke
debehnker@gmail.com
Submitted February 2025
By Lauren J. Crawford, MD
Moving Meditation & Revisiting Fight Club
Fight Club is a 25-year-old movie that is raw, irreverent, thought provoking, and clumsy. For me, it’s also nostalgic. Movie magic for a college student. I watched it again recently. The movie still resonates but for different reasons and through the lens of an older eye.
I’ve been asked twice to write for our wellness group. I give a wry smile and say ‘Sure!’. The truth is that I’m not good at wellness. I’m like a wellness dropout. I’ve done one therapy session in my life after my mom died and I found it awkward and hard to focus. I stupidly can’t meditate, and a long session of gentle yoga has the opposite effect of what’s intended.
But I’m good at looking at a hectic physician’s life and figuring out how to lighten the load and make it easier. Working to build egalitarian households, spending money wisely to offload home stressors, and saying no to unsustainable workplace practices are the big ones. Making life easier before you not just burn out but absolutely flame out. I have learned a few things in 15 years of practice.
Another big one – carve out time for your fitness and do not ask for permission to do so. Your kids will be fine. Let them have 30-60 minutes of a 1980’s childhood. Spoons will go missing. A giant hole will get dug in the backyard. They’ll probably live.
I learned a phrase about wellness where I found success and it stuck with me. Moving meditation. It’s the best tool in my toolbox for making me feel well. And, I bet I’m not alone. I’d also be willing to bet that there is a form of moving meditation that helps everyone. You just have to find your own groove.
For me its running and sometimes running to near exhaustion. Don’t worry folks, I don’t do this on OR days but all the other days are fair game. This is where my interest in Fight Club resurfaced.
I am Jill’s hypothalamus. Although I can enjoy it, walking doesn’t work for me. Running a moderate pace helps me focus on a problem and work on solutions because it dims the peripheral noise. Running hard or super long makes everything go quiet and primal. Maybe it’s because my body is so focused on surviving it. Maybe it’s the endorphins and other neuro signaling. It’s such a nice feeling to tune out all the noise except the immediate environment, my feet moving, and my muscles complaining. It depletes creative thoughts, but also the malingering worry. I sleep hard.
‘No distractions. The ability to let that which does not matter truly slide.’
I don’t look good either. I look basic and sweaty. Sweaty in a gross way, not in the rich pine-smelling sauna way. It’s good to lean into that every now and then when the world around us constantly creates content to help us approach perfection. It may be strange to hear this from a plastic surgeon but even plastic surgery doesn’t get you there. Lighting, makeup, filters, angles. It’s good to just exist in your skin and let yourself be imperfect.
‘After fighting, everything else in your life got the volume turned down.’
After the run, the effect does hold. After something challenging, I’m physically done but also the most mellow soul in the world. Beer thirty with no beer. Consistent work really infuses that mental Zen into my life and my personality takes a dive when I can’t do my thing. I don’t think this is something that science has a good understanding of although we know that exercise can occasionally outperform meds and therapy for depression. For doctors, I think it can temporarily drown out the bad clinic experiences, the frustration with an administrator, and even just the busy worker bee mentality to constantly chase productivity. We all need breaks even if we can’t find all the solutions in a day.
‘Being tired isn’t the same as being rich, but most of the time it’s close enough.’
I encourage everyone to find something relatively intense that uses their body that they hopefully like to do. Dirty minds may go where they wish. For others I imagine it could be dancing. The kind of dancing where distraction means you end up on the ground. Challenging rowing, yoga, rucking, or actual boxing. Choose your own adventure. But it has to be accessible and not a novelty because you have to do it with some frequency. And, you have to mostly like it. After 8 or 12 weeks, maybe it’s a habit.
Good luck with your very own moving meditation. Maybe a skosh less intense than fight club and with a side of better coping strategies. I highly recommend it.
Signed,
Jill’s Prefrontal Cortex
Dr. Lauren J. Crawford
laurencrawfordmd@gmail.com
Submitted February 2025
By Dr. Tina Philip
Change
“In any given moment we have two options: to step forward into growth or step back into safety.” - Abraham Maslow
For as long as I can remember, change is something that I have dreaded. I have always been a creature of habit and am most comfortable in my predictable routines. I wouldn’t consider myself a highly anxious person, but I definitely experience some apprehension when things don’t go as planned.
March 16, 2020. Most of you probably remember this time frame as when the pandemic became a reality for us here in central Texas. I remember this specific date as the day I opened the doors to my brand-new solo practice. Four days later, those doors “closed” as shelter in place orders went into effect. Talk about things not going as planned.
For many years prior, I had thought about changing my practice situation. I began to interview for other jobs, but I was fearful of change. What if a new job is worse than the one I already have? I did interview after interview, finding fault with each one because it was not exactly what I wanted. I realized that if what I wanted did not exist, I would have to create it myself.
Then the fear of starting a practice set in. What if I failed? What if it was too hard? I began the arduous process of building a practice. There was a cautious optimism as I started to make decisions on what my future practice would look like. Each step away from comfort was a step in the right direction, even if it did not feel like it at the time. Of course, planning for a global pandemic was not part of my business plan, but as it is with many other challenges in life, I rolled with it. It was daunting opening a new practice amid such uncertainty, but I was determined to press forward despite the challenges.
As you read in last week’s Sunday email, Dr. Brian Sayers has stepped down as chair of the Physician Wellness Program. When I first read it, I had a lot of feelings, the main one being sadness. In the TCMS Physician Wellness Program he has created something unique, the likes of which cannot be replicated, and for that, I cannot thank him enough. In a time where so many of our social connections seem superficial at best, the multiple facets of PWP have created tethers to something real; something that reaches the humanity of being part of this family of medicine. He has put himself into this program in more ways than any of us can fully understand. How can this program possibly continue without him in charge?
Then the reality of assuming care of this program in the interim set in. There is a lot of fear attached to taking responsibility for something so important to so many people and trying to fill some very big shoes. What if these emails stop speaking to people? What if I mess up this program? What if this program loses its spark? The answer to such natural worries is that our efforts will be guided by the TCMS Foundation board, and the program will continue, perfectly or imperfectly, to focus on the many needs of physician well-being.
I fully believe that everything happens for a reason and in its own time. As uncomfortable and unwanted as it is, change is necessary for the growth of this program. Maybe the point is not for the program to continue to exist as it is, but to continue to evolve and support the needs of our ever-changing physician community. Ultimately, while the Foundation board is its steward, the Physician Wellness Program belongs to our physician family. Although it will not be the same as it was under the familiar warmth of Brian’s leadership, I am cautiously optimistic that it will be what we need, because we will grow it together.
Tina J. Philip, DO
President, TCMS Foundation Board
tina.philip@gmail.com
Submitted January 2025
By Dr. Brian Sayers
Pilgrimage
In 1969 ethicist Paul Ramsey delivered a series of lectures sponsored by Yale Medical School and Yale School of Divinity, later published and widely disseminated, ushering in the era of modern medical ethics and bioethics. I came across my copy of it recently, dozens of Post-It tabs highlighting specific areas that meant something to me when I read it more than a decade ago in seminary. One particular line has always stuck with me: “The practice of medicine is one such covenant. Justice, fairness, righteousness, faithfulness, canons of loyalty, the sanctity of life, hesed, agapé or charity are some of the names given to the moral quality of attitude and of action owed to all men by any man who steps into a covenant with another… explicitly acknowledges that we are a covenant people on a common pilgrimage.” Whether viewed through a religious or secular lens, the idea is clear and gives us an admittedly idealized view of the doctor-patient relationship.
It got me thinking about the nature of the doctor-patient relationship. This partnership is critical to keeping both patient and doctor emotionally healthy and keeping both fully engaged in achieving optimal medical care. But this relationship can be a moving target in a rapidly evolving healthcare environment with the rise of medical consumerism and the ease at which our patients can research and become more active participants in medical decision-making. Described another way, “this relationship has been profoundly shaped by the human rights movement of the past several decades, and clinical care today is guided by norms of shared decision-making rather than benevolent paternalism.” Understanding, honoring, and navigating each individual patient’s desires and understanding of this relationship is critical in a working partnership with patients. Emphasis is now usually placed on patient satisfaction within this partnership, often emphasizing the physician’s bedside manner, but increasingly we also realize the importance of this relationship to the health of the physician. In the end, we will all have played both the role of physician and patient.
Defining the key elements in bedside manner is often made more complicated than it should be. A group from Harvard Medical School described 4 key components: trust, knowledge, regard (friendliness, warmth, emotional support), loyalty. More recently, a great deal of emphasis has been placed on the level of empathy that is both heartfelt and tangibly evident when a physician cares for a patient. There is great truth in this: a sense of understanding, of “shared suffering” is indeed what we all need to different degrees throughout our lives. In his landmark article, “The Nature of Suffering and the Goals of Medicine,” Eric Cassell notes, “the relief of suffering and the cure of the disease must be seen as two obligations of a medical profession that is truly dedicated to the care of the sick.” Others have noted that although empathy is an essential characteristic of a holistic physician, it can be a two-edged sword that, when unbalanced or overdeveloped, can affect objectivity, judgement and can be a significant contributor to physician burnout.
A more basic understanding of the relationship between physicians and patients might just involve kindness. Kindness is hard to define, but easy to recognize. When you think about it, kindness encompasses all the critical components of covenant that Ramsey spoke about at that gathering of great minds a half century ago. The more I have thought about kindness and now try to write about it, the more I realize how far short of it I fall most days, and how often I see and admire it in my colleagues, including my own doctors. It’s easy to find yourself in a hurry or frustrated or distracted and fail to see the shared humanity, even suffering in its many forms right there in front of you and to fully honor that covenant, that common pilgrimage physicians and patients take together. Perhaps intentionally honoring that high calling more often than we miss, it might just be the difference between loving our work and just having a job.
The legacy that we slowly mold, then leave behind after a long, or even a short, career in medicine may in part be defined by our diagnostic or therapeutic acumen, but when I consider my colleagues, past mentors and teachers, I think it is defined in a more lasting way by the characteristics that bond us with our patients and colleagues − patience, fidelity, empathy, love, but especially kindness. Yes. Kindness. That just might be enough.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Contact Dr. Sayers at briansayers24@gmail.com
Submitted January 2025
By Dr. Robina Poonawala
The Truth about Penguins and Doctors
A sprawling city bustles with the loud racket of morning hour rush. Crowds of commuters hurry past each other. Suddenly, one traveler bumps into another and sets off a shouting match.
This might seem like a typical morning in New York City, but the location is Antarctica and these commuters are chinstrap penguins. Named for facial markings that resemble helmet chinstraps, these flightless two foot tall birds live in and around Antarctica and nest in crowded communities called colonies. Many chinstrap colonies are home to hundreds or thousands of individuals and have a lot in common with manmade urban centers and their inhabitants.
Every November near the start of summer in Antarctica, chinstrap penguins arrive at their breeding grounds. There, they begin construction work. Mated pairs use pebbles to build nests that are up to 20 inches wide, like human neighborhoods arranging their nests side by side. They live in close quarters for safety ‒ a lone nest would be a sure target for skua, a predatory bird that swoops from the sky to snatch chinstrap eggs or chicks.
While penguins have evolved from flying birds, their superpower lies in being the best divers of all birds. To protect from the cold, they have dense feathering, and different species are distinguished by the colors of their heads. Female penguins lay one or two eggs and both parents take turns caring for the eggs. While one stays behind to keep the eggs warm and safe from predators, the other heads out to sea to feed on krill, fish, and squid. Once hatched, they are carefully watched for around three weeks when both parents may have to leave to forage for food while their chicks gather in the safety of the larger group of other young penguins called crèches for warmth and protection. This shared labor is so important that a penguin chick will not survive if it has only one parent. Chicks who are hungry may beg from other parents but there is no fostering, and adults will only feed their own offspring.
By March, when the chicks are nine weeks old and their downy baby feathers have been replaced by waterproof adult feathers, they plunge into the sea and forage for their own food. Mated penguins use calls to identify each other and their offspring. The penguins are monogamous and return to the same breeding partner year after year. As far as scientists can tell, there are no couples therapists or divorce attorneys in the colonies.
Observing penguins reminded me of the importance of community. We all need connection with each other for communities to survive and prosper and for our children to thrive in their formative years.
We feel security and a sense of contentment when we are with our peers ‒ the human version of the warmth and security that penguin communities model. Just as the penguins huddle together to survive harsh weather, shortage of food, and predators, together in community physicians and their families survive and thrive in spite of a wide variety of challenges, even predators, that we face daily as individuals and as a profession. We just have to stick together!
Dr. Robina Poonawala
Send comments to Dr. Poonawala at robina.poonawala@gmail.com
Submitted January 2025
By Dr. Brian Sayers
Real Change
When this comes out on January 5, there’s one thing we can count on: most New Year’s resolutions have already been abandoned. New Year’s resolutions fail because they are usually quick fixes for bad habits or other problems that involve a solution that is no fun and that we aren’t really all that serious about, often changes that involve weight, exercise, diet, alcohol, or spending. The plan, if it can be called that, typically overestimates the effectiveness of willpower, of muscling through a firmly entrenched behavior pattern, often ignoring the reality that change requires not just bulldozing over entrenched behavior, but actually understanding the behavior and why it makes us unhappy even as we persist in doing it. What some authors call “real change” is, well, real hard. It involves the big things in our lives that stand in the way of contentment, meaning, or honoring our deepest beliefs.
Real change isn’t hatched in a vacuum. It is usually a response to a sense of unease or sadness or yearning. The spark that starts the fire can be anger, grief, regret, shame/guilt, bad habits/addiction, relationship problems or loneliness. Each of these are serious internal feelings that must be explored, their roots understood for lasting change to be possible. One of the most rewarding aspects of working with physicians in PWP these last few years has been to witness and fully appreciate our capacity to make meaningful change. We see it in a variety of life-changing expressions − in committing to recovery, in reclaiming their calling by changing their practice setting mid-career, in seeking counseling, and sometimes by either saving or stepping away from a failing marriage. Willingness to change is an essential part of any life, but not an easy one. Theologian and ethicist Reinhold Niebuhr once noted, “Change is the essence of life; be willing to surrender what you are for what you could become.”
Real change starts with a careful assessment of what is not right with our life. The path toward change requires careful discernment in the context of our values, our relationships, what makes us feel content, and how a problem tangibly affects our day-to-day life. From this can emerge a carefully considered plan for a long-term change of course rather than a quick fix. Successful, real change is usually measured in months or years, through a series of innumerable small steps (and missteps).
When fully achieved, real change is a seismic movement of the soul, a visible expression of our values − what lies within our heart. With a sincere desire for change, as Sharon Salzberg notes “…. the engagement that results can be an openhearted demonstration of what we care about most deeply. Efforts toward change are an expression of our own innate dignity and testaments of the belief that what we do matters in this world. We engage not only to try to foster change right now − we engage to enliven what we believe to someday be possible.” In what Mary Oliver calls our “one wild and precious life,” we have been given many gifts, among them our sense of purpose, connection with others, grace, and an innate capacity for change − again and again − as we travel through this life in this world.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Contact Dr. Sayers at briansayers24@gmail.com