Wednesday, 25 April 2012

The Iceberg and the Tip

The tip of the iceberg of suffering is when someone kills themselves. Why it is the tip of the iceberg is because for every person who commits the act there are many many others who suffer depression and anxiety, often quietly, and for some, for their entire lives.

We each bring our reasons to the work we do and for me it must in some ways be tied up with my own father's depression and multiple suicide attempts when I was an adolescent. If I look at my motivations for blogging I find that I have the hope that maybe, just maybe, one of these posts might help someone feel less alone and be more open to asking for help if they are feeling depressed anxious or suicidal. This is a lofty goal, and some may say it is even Polyanna-ish- No matter, it has, at the least, the potential to be helpful, and, if you have read this far it is likely that it is not causing any harm.

If you click on the link below you will be brought to short 10 min NPR interview with the MD-author Danille Ofri as she talks about the shocking suicide of one of her mentor's.

Be well,

From Danielle Ofri's website:
Doctors’ Suicide
One of my most beloved mentors from residency took his own life. He seemed so much older to me at the time, but he was only 39 years old. In this interview on NPR, I talk about his loss, and read from the story I wrote about him, “Intensive Care.” This story, from the book Singular Intimacies, is included in a new anthology, Writer MD.

Thursday, 29 March 2012

Emotions, intelligence, and medicine

The NYT's article below outlines the conditions in which pretending we do not have emotions and suppressing our own reactions is unhelpful. Rather than seeing emotions as a sign of weakness, there is a lot of good evidence (particularly in the psychology literature) that the best decisions are made when we couple our rational (left-brain) to our intuitive (right-brain) and use BOTH together. I often get the impression that for many in medicine the "ideal" is to be 100% left -brain and to ignore those right-brain emotional messages. My own n-of-1 trial (i.e. my life) thus far has shown me that combining intuition & emotional-awareness in addition to rational cognition makes both me and those around me happier. That is true only of course, when I can actually do all that!

Doctors Have Feelings, Too


It was a little bit like looking in the mirror. We were the same height and build, the same age — mid-30s — and both of us had two young children at home. In another world, had we been friends, we could have easily shared clothing. But today it was me with the white coat, and her with the death sentence.

Except she didn’t know it yet.

It was the morning of Julia’s discharge from the hospital, and we were going through the array of cardiac medications stacked on her bedside table. She asked the same question about each bottle: “Will this medicine make my heart better?”

I squirmed painfully around the question, weaving ever more elaborate explanations about controlling symptoms, enhancing breathing, minimizing fluid imbalances, improving exercise tolerance. I told every truth about every medication, but I could not bring myself to tell her the ultimate truth — that a roll of the genetic dice had doomed the fibrils of her heart, that her only chance was a heart transplant, that because she was an undocumented immigrant this was nigh impossible. That her children would grow up motherless.

Last month, an article in the journal Health Affairs made headlines in the news media — “Physicians Are Not Always Open or Honest with Patients.” A vast majority of the nearly 2,000 doctors surveyed agreed that physicians should be fully open and honest in all their communications with patients, as the Charter on Medical Professionalism requires, but more than one in 10 had specifically told a patient something that was not true within the past year. Almost one in five had not revealed a medical error. More than half had framed a prognosis in a more positive light than was warranted.

The authors expressed concern that doctors were not fully living up to the charter; patients worried that they couldn’t trust what their doctors said. I also found the data disturbing, but for different reasons. I don’t think that doctors are generally a dishonest bunch. Yes, there are a few utter miscreants out there, and many more who could use a tune-up on their communication skills. But I suspect that the dishonesty that is being uncovered in a study such as this — and frankly, I was amazed that the number of less-than-truthful instances was so low — reveals more about the diagnosis of being human than anything else.

When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.

It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.

When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.

I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.

I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.

Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.

The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming ...” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.

Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.

Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.

I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.

Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author, most recently, of “Medicine in Translation: Journeys With My Patients.”

Thursday, 15 March 2012

Medicine with a Heart

There is an entire website and related discussion-groups based on "Remembering the Heart of Medicine" (check it yourself at that is a call to meaning and re-discovering the depth in the everyday. 

This pausing to ask "what matters?" and "where is the heart in this?" is not just for doctors to need to do (although as a group perhaps we need to be reminded even  more than most, due to both internal & external forces that lead us away  from the heart). 

Stumbling across the poem below was just such a moment's pause for me today, and now perhaps for you too?

Alice Walker 

My desire
is always the same; wherever Life
deposits me:
I want to stick my toe
& soon my whole body
into the water.
I want to shake out a fat broom
& sweep dried leaves
bruised blossoms
dead insects
& dust.
I want to grow
It seems impossible that desire
can sometimes transform into devotion;
but this has happened.
And that is how I've survived:
how the hole
I carefully tended
in the garden of my heart
grew a heart
to fill it.

Saturday, 3 March 2012

Nothing to do, nowhere to go, nothing to achieve

Why do I write these posts? (Other than to meet some of my ego’s needs).

My intention is the possibility that you, dear reader, may come across it at just the time you need to hear it. The proverb “When the student is ready the teacher will appear” has been true at important times in my own life. I remain grateful to many for putting stuff out there so that when I was ready it was right there for me.
Of course that also means that not everything is for everybody (and that’s where the delete button comes in real handy).

What follows is by no means an explanation of suicide or even of depression. It is rather an attempt to make sense of things out of my own experiences. So it may not ring true for you and is not meant as an explanation of anyone else’s behaviour.

Growing up with a depressed and suicide-attempting dad (he is still alive) has made me ask myself “how can I learn not to end up depressed and a victim of my own thoughts?” (and keep in mind that I chose to work in pediatric palliative care!)

Does any of this sound familiar?
·        You get married and think “I will never be lonely again!”
·        You get a job promotion and a raise and think “now everything is going to be perfect!”
·        After years of trying you finally have a child and now “life is finally complete!”

If only.

You know how foolish it is to think that any one thing is ever going to make “everything just perfect”.
Without the mythic and impossible promise of “everything will be perfect when…” the advertising industry would grind to a halt in a heartbeat!
Does any of this sound familiar?
·        You lose your job, and now your life is ruined!
·        You get a frightening diagnosis and now your life is over!
·        Someone you love dies, and now your life will never have a good moment again.

Are any of these thoughts true?
Even if they feel really true at the time just how long do they last? Forever?

Things happen, we can’t control most of it, and we decide, on the spot, that they are great or terrible.  But when you look back at what you thought was bad it rather turned out to be good, and  what was supposed to great and long-lasting was not so.
·        I would not wish this diagnosis of cancer on anyone but it has changed my life and I have grown”.
·        “Losing everything I had thought I needed to be happy has turned out to be the best thing that ever happened to me”

What to make of all this?
Not only do we not know what is going to happen next, but our initial judgements about what is good or bad are often wrong, or at least it is often more complicated (the good/bad judgement) than we initially thought.
All these things that happen are descriptions of our life situation, but not of our LIFE.
Things happen to us and we get buffeted around by them like a balloon in the wind – Sometimes we are up and sometimes down – and all that is still not our LIFE but is rather our life-situation.

So what is our LIFE if it is not all these things that happen?
Is it possible that LIFE is what is experiencing all these things?
This LIFE (versus life-situation) is what we sense when an island of calm opens up in those spontaneous moments where thinking abates and we just are – We all get these moments  from time to time –
·        Watching your 8 year old eat an apple;
·        Diving into a calm lake;
·        Sitting quietly and watching the snow falling just outside the window.

So what's the big deal about the difference between LIFE and life-situation?

If you believe that your life situation is the same as your LIFE, if you believe that your self-worth is hinged on this or that, then you are vulnerable to losing your “reason for living”.

Do you really need any justification for being alive?
Does any form of life need to “do something” to justify its existence? Does a flower or a bird need to justify its own existence to itself or to others?  

There is no judgment of good or bad in “LIFE” but lots of judgements of good and bad in “life-situations”.
As far as your LIFE is concerned there is nothing to do, nowhere to go and nothing to achieve.
By all means go ahead and do, go, and achieve, just see them as choices to make and not as necessary justifications for your LIFE.

If you believe that what happens to you is the same thing as your LIFE, as who you really are, then the thought “I do not deserve to live” can become a wrong thought believed.
And that can be a fatal mistake.

Friday, 17 February 2012

I, Me,& Mine = The misery of taking things personally

Case 1- If you get a hit on the back of your head and then spin around and see that it was caused by a small tree branch that fell, then how do you feel?
Case 2- If you get the exact same hitting sensation on the back of your head and then spin around and see that it was because you were struck by someone holding a small tree branch in their hand, then how do you feel?

Do you quickly rub your head and then get on with your day in the first case?
Do you take the second case personally and does it then result in a rush of intense potentially long lasting negative uncomfortable feelings compared to the first case?

What does it mean to take things “personally” and all the unwanted baggage that goes with that?

“How could she talk to me like that!”
“I can’t believe he treated me that way!”
“Who do they think they are?!”

Is it possible that being unhappy/miserable/suffering boils to down to taking things personally? But how could I not take things personally when someone just did or said something to ME?

I think this points to the question of who we think we are (and sometimes we are even told exactly that (often in a very loud voice) as in; “Who (the hell) do you think you are!” Maybe the best answer to that is; “Good question!”

Who am I?
  • Am I my body? – If so then if certain body parts are removed or change am I less myself?
  • Am I my thoughts? – If so then my thoughts (and even core beliefs) have changed since I was born – does that mean I am not “me” anymore?
  • Am I the totality of my life experiences? – If so then would I not be “me” (the me inside that observes & remembers) if I had had different experiences (e.g. grew up in a different country)?
  • Ask the same question (i.e. “Am I this, Am I that?) and the answer always comes back as  “Well,  yes and no”. It seems that nowhere I look do I find a stable enduring sense of “me” other than just this “feeling”.

Have I said and done things I never imagined I would ever say or do (answer = for sure!).
So is it possible that even I myself am not 100% sure who “I am”?
I think so.

If even I myself am not sure who “me” is then how could anyone else really know who “I am”?

If no one else can know who I am then how could anything they ever do really be “to me”? Whatever they do is, at worse, being done to their version of who they think I am, as opposed to the “real” me – which is not even really knowable anyway.
Add to this that most of us spend our time worrying and thinking about how everything relates back to ourselves (the internal narrative that is mostly an ongoing story of “me”). Given all that then whatever goes on is likely not really about “me” at all. That does not mean that things are to be ignored but rather that seeing them for what they really are means seeing that things happen as a result of all kinds of factors that do not all revolve around “me”.

So if you come at me with a stick I will still run or turn to defend myself, but I will do so with trying to see what is happening from an understanding that trying to hurt  me is not so much about “me” and likely more about what is going on in the other person. Taking things less personally in this way feels like a path to less misery. At least it has for me so far  as I continue in my “n of 1 trial” that is trying to answer/live out the question: “How to live?”

What do you (whoever “you” really are!) think?

Thursday, 9 February 2012

Self-compassion=The opposite of being selfish

Although last week's post was about what mindful speaking might look like, alert readers pointed out that my using the term "personal failure" was harsh at best, and they are correct. 
So what does it mean to be so self-critical? Is it possible that there is a direct connection between self-criticism/self harshness and judging others? 
I think so. 

Maybe I need to re-read the textbook chapter on "professional self care" that I co-wrote where i say that "Care of others begins with caring for ourselves".
If we are harsh with ourselves and self judge  then why should we expect to be able to be open and non-judgmental of others?
If we cannot laugh at our own foibles and little failures then do we really expect that we can do the same for others?
Wouldn't it be the wiser path to practice being compassionate with the one person we are always around?
Why not be kind to ourselves as a way to practice being kind to others?

Self compassion is not the same as self esteem as outlined by this quote taken from the website of Kristen Neff  - her website is a great resource - You can even take a self-compassion quiz to see how you score for yourself! (From Kristin Neff's website -

"Although self-compassion may seem similar to self-esteem, they are different in many ways.  Self-esteem refers to our sense of self-worth, perceived value, or how much we like ourselves. While there is little doubt that low self-esteem is problematic and often leads to depression and lack of motivation, trying to have higher self-esteem can also be problematic.  In modern Western culture, self-esteem is often based on how much we are different from others, how much we stand out or are special.  It is not okay to be average, we have to feel above average to feel good about ourselves.  This means that attempts to raise self-esteem may result in narcissistic, self-absorbed behavior, or lead us to put others down in order to feel better about ourselves.  We also tend to get angry and aggressive towards those who have said or done anything that potentially makes us feel bad about ourselves.  The need for high self-esteem may encourage us to ignore, distort or hide personal shortcomings so that we can’t see ourselves clearly and accurately. Finally, our self-esteem is often contingent on our latest success or failure, meaning that our self-esteem fluctuates depending on ever-changing circumstances.

In contrast to self-esteem, self-compassion is not based on self-evaluations. People feel compassion for themselves because all human beings deserve compassion and understanding, not because they possess some particular set of traits (pretty, smart, talented, and so on). This means that with self-compassion, you don’t have to feel better than others to feel good about yourself.  Self-compassion also allows for greater self-clarity, because personal failings can be acknowledged with kindness and do not need to be hidden. Moreover, self-compassion isn’t dependent on external circumstances, it’s always available – especially when you fall flat on your face!  Research indicates that in comparison to self-esteem, self-compassion is associated with greater emotional resilience, more accurate self-concepts, more caring relationship behavior, as well as less narcissism and reactive anger."

Be well,


Friday, 3 February 2012

Me talk good: Right speech

Last week's post was an example (of my personal failure) of the struggle to speak mindfully. 
So what then might speaking mindfully look like? 
How can we know if what we are about to say is "mindful" or not? 
What follows is paraphrased &  attributed to someone named Sid(-dhartha) a few thousand years ago
It is a pithy & revealing set of suggestions for thinking critically about how we use speech.

"[1] In the case of words that I know to be unfactual, untrue, unbeneficial, unendearing & disagreeable to others, I do  not say them.

[2] In the case of words that I know to be factual, true, unbeneficial, unendearing & disagreeable to others, I do not say them.

[3] In the case of words that I know to be factual, true, beneficial, but unendearing & disagreeable to others, I have  a sense of the proper time for saying them.

[4] In the case of words that I know to be unfactual, untrue, unbeneficial, but endearing & agreeable to others, I do  not say them.

[5] In the case of words that I know to be factual, true, unbeneficial, but endearing & agreeable to others, I do not say them.

[6] In the case of words that I know to be factual, true, beneficial, and endearing & agreeable to others, I have a sense of the proper time for saying them. 

Why is that? Because I have sympathy for living beings."

An good additional question to ask is: 
"Do I speak with a kindly heart, or am I inwardly malicious?

Be well,

Thursday, 26 January 2012

Mindfulness In Practice

What does Mindfulness mean in practice?

Part 1- Letting Go (or "Getting out of our own way")

When you hear someone say “just let it go” what does it mean and how can it sometimes be  helpful and at other (i.e: most) times just be  irritating and unhelpful? This week during  a hospital meeting I decided, in the heat of the moment, to make a comment about how I saw a clash between the mandate of administration (to keep the hospital on budget and to provide clinical care) and that of  the academic mandate of physicians (that includes clinical care but also teaching and research). While making “my point” I realized that the way I had framed what I said made the administration out to be the bad guys and the physicians out  to be the good guys. In retrospect my comment did not further creative problem solving and only reinforced the unhelpful and untrue  way of seeing the problem as residing in  “them=bad guys” and not at all with “us=good guys”. Thinking all of this over later on in the day I regretted having spoken at all and wished I had better thought through the intention behind my speaking. My intentions in fact included a desire to find reasons why "we"  were in the right and 'they" were in the wrong, yet again. Rarely is this a helpful position to take. Feeling regret over what I said I quickly reached a point where I learned what I could from the episode and further ruminating, further wishing I had not said anything at all, became pointless because no matter how hard I may re-imagine the past I really cannot go back and undo what was done. At that point all that is left to do is to “let go” of my disappointment in myself. But how to do this when the feelings (e.g. disappointment) appear to have a life of their own?

Mindful practice at that point would be to “stay with energy and drop the storyline”. That is, to be aware of the thoughts and feelings (i.e. regret and feeling bad), accept these thoughts & feelings as they are (rather than try push them away or deny them) and then, seeing the futility of repeating the unhelpful negative thoughts, make a conscious choice to stop the “repeating story line/internal narrative” and just accept the “negative energy=feeling lousy”. By doing this, that is stopping the thoughts from ruminating by seeing them for what they are, the energy (or mood if you prefer) is like a fire without fuel, it just dissipates on its own.

Seen in this way "letting go" is not something that we actively make happen but rather a process that happens on its own when we stop fuelling the fire of thoughts that are unhelpful.
So while we cannot make letting go happen we can stop getting in the way of its happening on its own. Getting out of the way means accepting the feelings and seeing unhelpful ruminating thoughts for what they are. After all, continuing to replay what already happened over and over again in our minds is like “continuing to wish for a better past”. 

Thursday, 19 January 2012

Mindful leadership training

The article below describes what a leadership program could look like if we applied what we already know from cognitive psychology to leadership training, namely; 

1. Developing people is a process — not an event.
2. Staying in just our heads  (cognition) is not enough, there needs to a lived experiential component  for learning/change to take place.
3. Mindfulness based on an "awareness of self" practice (that is not quite the same as practising "self-awareness") is a slow and steady way to cultivate progressive change in behavior (i.e. from reactivity to responsiveness) .
4. People grow best with others, in community
5. Everyone wants and deserves to grow (and i would add, to be happy).

What caught my attention in this article was the paragraph: "What if, instead of stuffing people with curricula, models, and competencies, we focused on deepening their sense of purpose, expanding their capability to navigate difficulty and complexity, and enriching their emotional resilience? What if, instead of trying to fix people, we assumed that they were already full of potential and created an environment that promoted their long-term well-being?"

This is from the Harvard Business Review.
Harvard Business Review Blog Polly LaBarre Polly LaBarre is the Editorial Director of the Management Innovation eXchange.

Developing Mindful Leaders Organizations invest billions annually on a success curriculum known as "leadership development," which ends up leaving so much on the table. Training and development programs almost universally focus factory-like on inputs and outputs — absorb curriculum, check a box; learn a skill, advance a rung; submit to assessment, fix a problem. Likewise, they leave too many people behind with an elite selection process that fast-tracks "hi-pos" and essentially discards the rest. And they leave most people cold with flavor of the month remedies, off sites, immersions, and excursions — which produce little more than a grim legacy of fat binders gathering dust on shelves. What if, instead of stuffing people with curricula, models, and competencies, we focused on deepening their sense of purpose, expanding their capability to navigate difficulty and complexity, and enriching their emotional resilience? What if, instead of trying to fix people, we assumed that they were already full of potential and created an environment that promoted their long-term well-being? In other words, what if cultivating a successful inner life was front and center on the leadership agenda? That was the question Todd Pierce asked himself in 2006 after years of experimenting with the full menu of trainings, meetings, and competency models in his capacity as CIO of biotechnology giant Genentech. He had just scoured the development reports of some 700 individuals in the IT department and found that "not one of them had an ounce of inspiration. I remember sitting there and saying, 'There's got to be a another way.'" At the time, Pierce was benefiting personally from work with a personal coach and had recently woken up to the power of the practice of mindfulness. He called in a kindred soul, Pamela Weiss, a long-time executive coach and meditation teacher, to help design an experiment that would cast out the traditional approach to leadership development to focus instead on helping people grow. "If you want to transform an organization it's not about changing systems and processes so much as it's about changing the hearts and minds of people," says Weiss. "Mindfulness is one of the all-time most brilliant technologies for helping to alleviate human suffering and for bringing out our extraordinary potential as human beings." Pierce and Weiss distilled a set of principles that form the basis of what became the "Personal Excellence Program" (PEP), now heading into its sixth year inside Genentech (Pierce left the company this fall after 11 years to join Together, these pillars offer up a short course in unleashing human capability, resilience, compassion, and well-being (and they're unpacked in even more detail in Weiss and Pierce's entry). 1. Developing people is a process — not an event. "Development is all too often considered a one-time event," says Weiss. She and Pierce designed PEP as a ten-month-long journey that unfolds in three phases, with big group meetings, regular small group sessions, individual coaching, peer coaching, and structured solo practice. 2. People don't grow from the neck up. Too much training focuses on the the mind — it's about transferring content. "We talk about the head, the heart, and the body," says Weiss. In fact, they do more than talk about it — they enact it every day at the start of every meeting. The "3-center check in" is the gateway drug to mindfulness. As Weiss describes it: "You close your eyes for a moment and you notice, 'What am I thinking — what's happening in my head center,' then you notice, 'What am I feeling — what's happening in my heart center.' then, 'What am I feeling — what's happening in my body.' It's a way in which people start paying attention and practicing mindfulness without ever practicing meditation." 3. Put mindfulness at the center (but don't call it that!). Weiss and her team were careful to keep the language of specific belief systems and religions out of PEP. The program revolves around three phases: reflection on and selection of a specific quality or capacity you want to work on (patience, decisiveness, courage); three months of cultivating the capacity for self-observation; and the hard work of turning insight into deliberate, dedicated, daily practice. 4. It's hard to grow alone. "People grow best in community," says Weiss. "People don't grow as well just reading a book, getting an online training, or just taking in information. There's an exponential impact in having people grow and learn together." That's why the PEP "pod" (small 6-8 person group) is the main vehicle throughout the year. 5. Everybody deserves to grow. Pierce felt strongly that PEP should be available to people across the board — not just the usual "stars" — and that it should be voluntary. "The program is by application and not declaration," he says. As PEP heads into its sixth year at Genentech, some 800 people have participated in the program. (Weiss added a graduate curriculum and a student training program to create "PEPtators" as few people want the journey to end.) The impact has been nothing short of transformative for individuals and organization alike. When Pierce took over the IT department in 2002, its employee satisfaction scores were at rock bottom; four years into the program, the department ranked second in the company and is now consistently ranked among the best places to work in IT In the world (even in the wake of Genentech's 2009 merger with Roche Group — always a turbulent and dispiriting experience).