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,
S.

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”. 

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?"

B-MD
____________________________________________________________________________
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 salesforce.com). 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).

Family Meetings and Decision-Making Capacity

To me,  a family meeting with the healthcare team is like performing an operation in the OR is to a surgeon -  it is an intervention that goes best with careful planning (who , what , when , where , why , how) . There is now another element to family meetings and that is decisional fatigue for both patients/families and for the healthcare workers too! In both the New York Times and in the Journal of Palliative Medicine there are articles that bring together data on the science behind decision making and how we need to take this into consideration both for the families and also for ourselves.

First there is the pre-meeting planning: 

• Who will be there? Who should not be there? What is the ratio of professionals to family?
• Where will it best held? 
• How can we make sure that the family is represented and enabled to speak by reducing language barriers and inviting them to bring to the meeting anyone they think can help them?
• Will there be a "pre" meeting of professionals to review some of the above issues , and decide how the meeting will go (who should "chair" the meeting) and what common objectives are?

Then at the meeting itself:

• Providing choices and options (and showing respect)  by leaving seating open so that family chooses where to sit first and then the professionals sit next. (ie: some of us stand up away from the chairs when the family walks in to give them a chance to choose where to sit)
• Self introductions of all at the table ( avoiding  "and those are the medical students" non-introductions)
• Starting the meeting by asking what the family hopes to get out of the meeting and then asking what they understand about the situation.
• Being clear about time available ("we have an hour..."), and what may not be possible.
• Negotiating the issues in a priority sequence so that if time runs out the most important issues have been addressed first.
• Addressing issues on both the family list and the professional list.
• Summarizing and planning for concrete specific follow up
• Offering "last  words" to the family just before the close of the meeting("Is there something else you would like to say?"

Now,  in addition to all the above,  we probably should also taking into consideration the time of day of the meeting - At the end of the day decision making may be quite different than at the beginning, especially if it has been a long day for the family who have had one heavy conversation after another and then at the end of the day are asked to "meet the palliative care/or other team".

Excerpt from the JPM blog : http://palliativejournal.stanford.edu/?p=3149: 
Decision Science meets Decision Fatigue 
September 29, 2011 | Author Suzana Makowski MD 


When do we typically conduct family meetings?
Are you, and the families/patients hydrated, fed, or hungry and fatigued?


Add in decisions that palliative care teams are often brought into: at the height of crisis, at the end of the day, after a slue of options have been presented to patients over a day or series of days.  Now consider the NYTimes article about decision-fatigue or “ego depletion”:  We make poorer choices if decisions are made at the end of the day, after other decisions (difficult or not) have been made – i.e. if we have “decision-fatigue”, or if our blood sugar is low.


Given this information, and honestly, for me it was new “decision-science” information, consider the following questions:


Should we reconsider other aspects of when and how we schedule family meetings?
Is this an argument to study the outcome of meetings held early or late in the day?
Does it account for differing decisions made early in treatment course vs. late?
Should there be food and beverage offered during or prior to these meetings (not only for the clinicians, but for families?)

Self-compassion: A work in progress

Now on day 5 of a pretty awful cough I decided to stay home from work today, something I do maybe 2-3 days a year at most (my place of work is a children’s hospital). Yesterday I felt guilty for my loud coughing and had the feeling that my presence was likely unwelcome as a spreader of disease. So, I stayed home today, pager on, colleagues at work notified of my staying home, and switched my laptop on and started the day with the hope that I would get through editing a research paper that others are waiting for me to complete so they can then do their parts. What ended up happening was that I just felt physically unwell and achy all day and did not get any of my hoped for writing/editing done. Instead I did a bunch of tasks around the house I rarely have time for (putting up a bookshelf for example) and puttered around checking my emails pathologically often but not really doing anything with the ones that required more than a few minutes thought to answer. In the end I did not do much work at all – had I done no work it would have ultimately made no difference at all – I will continue to deal with the never-ending “things to do list’ when I feel better. But I spent most of the day with a vague sense of guilt (after all I am not really that sick) and dissatisfaction that in the end served no-one, myself included. If you ask me what I would advise a friend or colleague if they were to take a sick day I would say to them, with a semi-lofty combination of concern and loving-kindness “to stay home and take it easy, don’t do any work, just take care of yourself”. Why am I harder on myself than I am on others (at least for this kind of thing)? I suspect that many of us are the same – we would advise those we care about to rest when ill and put things in perspective, but are less likely to feel “ok” with applying that to ourselves. All of this is in the context of me being more frequently asked (and wanting to be asked) to write about “self care” in medicine. I am also the one who started a “work-life” balance email list at work and a dedicated  facebook group. It appears that I need to both listen to my own advice and put my words into practice (“walk the walk”), even as this rant/blog has me “talking the talk” yet again.

MD's & Bullying

This article on MD’s and bullying in the NYT's -http://www.nytimes.com/2011/05/08/opinion/08Brown.html?_r=1&scp=1&sq=md%20bully&st=cse (actually it also includes RN’s as well) speaks to an ongoing problem in hospitals that, naturally, just reflects what is “out there” in the larger world. So how come this behavior continues even though we all recognize it when we see it? Well for one thing, maybe we don’t always see it. While I know when I feel bullied by someone else am I sure that I am aware of when my behavior is felt as bullying by another? Not necessarily. So what to do about a behavior that most of us, at one time or another are ourselves perpetrators of without us even knowing it? The NYT’s article points to some possible solutions (e.g. clear rules) but does not go far enough to the core of the issue to make a difference. After all, if we are not even aware of our behavior and its effect on others then what hope is there that we can change? A deeper answer is to be found in what Virgina Satir called the core concept of awareness of self, awareness of the other, and awareness of context (you can find lots on Virgina Satir on the web). So like in real estate where the 3 most important things are location location location, the 3 most important things in both not being a bully and how to best respond to bullying are awareness, awareness, awareness. (And I also hope that am more successful with awareness practice than I have been with real estate!)

Ok you think (maybe) that sounds reasonable but how to do I do this? What do I need to do to be more aware (of self other and context)? – One answer is that there is nothing to “do” other than stop doing for a moment and observe – observing your own reactions as they happen creates a tiny space between “me” and “my reactions”. When this is seen and felt then the space created holds the potential for changing a reactive (e.g. angry) response to one that fits better with what you really want and what would really be helpful and true. How do I know this? The only way anything is ever known or learned, I have seen  and felt  myself the difference in my life, in the moment, when I am aware and live that way and when I am not.