Bowling Alone or Kicking in Groups? Wellness concerns…

I’m part of WellDOM, the Wellness initiative within the Department of Medicine at University of Colorado. As such, I continue to support the idea of Sprints, the way we boost physician and team efficiency and effectiveness using the Electronic Health Record. However, we know that a large part of physician burnout and wellness have to do with other components: a Culture of Wellness and Personal Resilience, in addition to Practice Efficiency.

In thinking more about these broader components, I’m reminded of the work of Robert Putnam’ Bowling Alone, a towering work, documenting the decline of civic virtue and engagement in this country, illustrated most profoundly by the fact that membership in bowling leagues has declined 40% from 1980 to 1993, while individual bowlers rose by 10%. There has been a dramatic drop in face-to-face social gatherings outside of work in the past few decades, and the thought is that this decline in the social fabric has led to isolation, loneliness, and a general decline in civility and personal resilience. See the recent Atlantic article “Kicking in Groups” on this, also.

We’re looking for objective measures that might allow us to survey for and detect burnout and resilience, that might get past ‘soft’ measures like “do you feel burned out” and perhaps measure “Do you have social groups that you meet with regularly at work” or “Do you have social groups that you meet with regularly outside of work”, and also “Do you meet regularly with a mentor or mentee?” We believe that measuring such behaviors MIGHT be a more objective way to determine who is more protected, and who is vulnerable, to burnout.

CMIO’s take? Physician/provider burnout is a real thing; difficult to address; and may be embedded in a larger change in the social fabric. Are you having success thinking about and intervening in this fraught area? Let me know.

AMA Joy in Medicine recognizes – University of Colorado School of Medicine

We are honored to be among the organizations awarded the inaugural Joy in Medicine honor. We applaud the AMA for standing up a framework that all healthcare organizations can pursue, to ensure that the work-life balance of physicians is considering in the coming topsy-turvy days of healthcare.

Physician burnout is a national epidemic, with suicide rates among doctors 2-3 times the average for US adults.

CMIO’s take? Come join us on this stage! We should not rest until ALL healthcare organizations win the Joy in Medicine award. ALL our healthcare colleagues deserve this.

Giving Advice? How to do it right (NYTimes)

I love this: giving advice is often not giving advice.

This Zen statement is not about Zen.

Our physician informatics credo emphasizes relationships .

“We improve physician and team wellness and effectiveness by building extraordinary relationships and innovative tools.”

Extraordinary Relationships come from excellent communication.

Excellent communication comes from listening well.

Listening well comes from a position of empathic understanding.

Empathy is what we all crave. We should all learn the skills to exhibit empathy to others; this is the only way we might receive some in return. This article is a start.

NYTimes Magazine travelogue photos (Shinrin-yoku, and take a breath)

from NYTimes

Is this goofing off, or is this about personal resilience? Like the idea of “forest bathing” (youtube) or shinrin-yoku, I seek out opportunities during the day to pause and reflect, and walk where there are trees. Sometimes this ends up being an online article with lots of nature photos 😦 .

Hey, you do what you can.

The photos from this travelogue are pretty amazing.

And, did any of you watch the movie “Crazy Rich Asians”? The skyscraper-top boat-like structure in Singapore is apparently an Infinity Pool and is REAL (see the background in the photo at the top). Gotta put this on my bucket list.

CMIO’s take? Harken back to the tripartite model of physician burnout and resilience: a) develop a culture of wellness, b) work on improving practice efficiency and c) work on personal resilience. And ‘forest bathing’ belongs firmly on this list. Take a moment.

How to Actually Focus on What You’re Doing (NYTimes)

Cal Newport interviewed in the NYT

In the blizzard of our daily work and internal and external pressures, maybe think of putting the blizzard aside at times, and focusing on Deep Work (which I reviewed previously) or pursuing ONE Thing (also previously reviewed). Sometimes it takes a second or third exposure (or many more) to have a new idea really stick. Well, here it is again.

When I have the discipline to be present, to be aware of the cacophany that constantly blares and swirls around my head and consciously place it to the side for a few hours, or even an entire morning or whole day (what a luxury, but also a necessity), then I feel like I can accomplish something substantial.

Here are a few distractions pulling me away:

  • Post-office syndrome: 4000 items in my email inbox, 1000 unread.
  • External crisis: Colleagues whose Citrix or EHR (electronic health record) or Dragon (speech recognition) or other EHR-related tool does not work and “DON’T YOU KNOW I CAN’T TAKE CARE OF PATIENTS RIGHT NOW?”
  • “I would like a report pulled from the EHR and my request is too low priority, can you fix that?”
  • “I need something fixed in the EHR, can you help me?”
  • Shiny new object: “Hey, here’s a new opportunity to collaborate on a project!”

Here are a few BHAGs (big hairy audacious goals) just begging for time and effort from quadrant four (Low urgency, high importance, from Getting Things Done) :

  • Design and write a follow-up paper on EHR optimization through Sprints
  • Write the next QI/research proposal on patients viewing images online
  • Write the next QI/research proposal on using speech recognition tools in the examination room
  • Help an innovation partner company deliver a minimum viable product related to new prescribing tools linked to the EHR
  • Help an innovation partner redesign physician training for EHR
  • Help craft the vision and curriculum of EHRs role in telehealth for a national organization
  • Help craft the vision and curriculum of informatics training for medical students
  • Learn to be a better mentor: improve the quality of meetings-with and benefit-to mentees and direct reports

CMIO’s take? I realize that any ONE of my BHAGs could be THE ONE THING that I focus on and made substantial progress on. What are YOU focusing on?

Time Poverty (HBR)

This is a ‘wow’ moment. We may pursue wealth as we scramble up the corporate ladder, but we may all experience time poverty. What is the trade off? We don’t usually see our lives as comprised NOT ONLY of the wealth we pursue, but also the precious minutes that pass WHILE we delay gratification, WHILE we trade time for other items of “low cost.”

For example, how many of us shop across airlines and end up purchasing the ticket for $379 that my have a 2 hour layover instead of the direct flight for $450? I know I’ve been guilty of that tradeoff. And yet, for the $71 savings, you have relegated yourself to sitting in a distant airport, NOT being at your destination, and not being at home. Is your time worth more than $36 an hour?

Now I’m going to refer to Tim Urban’s blog WaitButWhy, specifically a post he wrote about “Your Life in Weeks“. Read it. You’ll look at your life differently, and maybe reconfigure your priorities. It is thought provoking.

CMIO’s take? This is a short post; spend more time with the linked articles. Socrates said “The unexamined life is not worth living.” And our contemporaries expand this in ways relevant to our modern, too-rushed lives. Spend some time on these ideas. And, let me know what you think!

Time management regret? (NYTimes) Work-life (im)balance? Start now.

We can all benefit from reminders. And self-forgiveness. And taking a single step, (or creating the “next action”) as David Allen says in his book “Getting things Done (book summarizing video).” Atomic Habits (book summarizing video) is another book with similar suggestions. There are a growing number of books, articles, videos dedicated to this topic; go ahead and explore. After all, the ancient Chinese saying is: “The journey of 1000 miles begins with a single step.”

We are all burdened with too much work and too little time. If we are not careful, our work overwhelms other parts of our lives and we lose balance. I struggle with this myself. It is helpful, then, to have a quiver of tools to deploy in the moments when your self-awareness kicks in: “whoa, I’m out of balance; I missed my kid’s field hockey game, or that school event, or the dinner with my family.” Or maybe all of the above. 😦

In these moments, as the article suggests, break it down to ONE action.

  • Forgive yourself. Move past it and commit to behaving differently NOW.
    Self-disappointment gets in the way of personal progress.
  • Do ONE thing. Leave today, early enough to go exercise, for example.
  • Find a SMALL thing to change. “Managing time” is a huge monster, but getting THIS particular project started involves finding THAT one phone number. There. That’s progress.
  • Read a book about process (This works for me, instead of doing better, read about doing better, maybe implement ONE idea from it, and rejoice. As you read more and pause and reflect more often, you WILL find more opportunities to change or establish a new habit. It is okay if this takes weeks, months, years, decades. We are all works-in-progress.)
  • Set yourself a task for teaching Work-Life balance. Nothing like see one, do one, teach one, like we did in medical school. Or worse yet, don’t even see one or do one, but figure out how to TEACH one, and that forces you to examine yourself and pay attention. (Speaking of which, come to the CMIO Leadership Academy where I’m going to be teaching … Work Life Balance). Hilarious!

CMIO’s take? Having trouble managing time or really getting started changing yourself? Break it down into a small “next” action. Read the article. Watch a YouTube video. I’m surprised at home many authors now offer their best ideas on video or in short articles. Are Books “so last century”? Maybe so.

I wanted Vicodin, not Herbal Tea (nytimes)

We are in the midst of a national opioid crisis. It is a crisis, partially, of our own making. In the past decade we physicians were criticized for not adequately addressing the pain of our patients, to the point of creating another vital sign: “pain score.” And then dutifully tracking this score and catering to it, and addressing pain, often with rehab therapy, with more aggressive interventions, injections, surgeries, and, yes, sometimes with pain meds, including narcotics and anxiolytics.

And on top of this, we layered “patient satisfaction” as a rubric, and now a method of affecting physician reimbursement. What could go wrong? Isn’t satisfying our patients a core precept of our identity as physicians?

Actually, come to think of it… no.

We are here to help our patients get better.

To cure sometimes, to relieve often, and to comfort always.
–15th century folk saying

But there’s nothing in that saying that says “and always write for a narcotic script if you’re in danger of getting a low satisfaction score.

So, here we are, with an opiate crisis, and faced with the very difficult task of reducing or eliminating opiate use in patients whom we have PUT on chronic opiates. So, this NYtimes article is timely and fascinating.

In fact, we are in the midst of designing and implementing an ERAS program (Enhanced Recovery After Surgery) in our health system, to entirely eliminate the use of opiates before, during and after surgery. Apparently pioneered by surgeons at Duke University, we are well on the way to experiencing similar benefits for our patients, faster recovery, reduce hospital stays, higher patient satisfaction.

This is reminiscent of Atul Gawande’s book “Better” where he describes the idea that “If even elite athletes have coaches to improve their game, maybe surgeons should have coaches.” And then finding that having a former mentor observe him during surgery, he received pages of notes on how to improve his operating technique and outcomes. Hmm. We should do more of this, inspecting our usual practices, and working out how to continuously improve.

CMIO’s take? There is always something new to learn.

On Master Cleanse (or, is CT Lin crazy?)

image from

Thanks to @ToddMeier, one of my IT colleagues at UCHealth.  He explained to me the benefits of periodic modified fasting.  This discussion put me on to watching a documentary about the Science of Fasting on YouTube, and then of course reading the book “Master Cleanser“.

Of course, I do not subscribe to non-medical claims about cayenne pepper boosting the blood circulation or “the only thing you lose during this, is mucus and clogged lymphatics”. But, look past all that.

If you know me and my writing, I like trying new things.  This certainly falls into the category of “something new.”  Perhaps the most powerful vision from my reading, is the idea that our Mastodon-hunting ancestors would have enormous protein meals and then perhaps not eat for weeks while the tribe looked for additional prey.  Fasting and starvation are a normal, expected physiology for our human bodies. We know that the human body can go weeks without nutrition.  Modern life, with 3 meals per day, and easy access to sugar and fat, and our tendency for overeating based on stress, eliminated the possibility of activating our fasting metabolism.  Various reports of improved energy, cognition, reduced inflammation and joint pain, and perhaps a resetting of our sugar cravings, were all attractive aspects of trying this. My colleague at University of Colorado has written extensively on this (The Fat Switch and The Sugar Fix).

This sounds somewhat reminiscent of the Paleo diet and perhaps pseudo-scientific hocus-pocus.  Nevertheless, with my underlying gout, and this desire to try something new, I broke through several weeks of ambivalence and decided to prepare the lemon drink proposed by this “master cleanse.”

The drink comprises half of a squeezed lemon, 2 tablespoons of pure maple syrup (200 cal), and a pinch of cayenne pepper.  This is added to an 8 ounce cup of water, and preferably consumed hot.  It is surprisingly tasty for what I considered a “deprivation” diet.

I am now on day 3 of my master cleanse and feeling good.  I am experiencing no hunger, I went to my usual 90 minute karate workout, I did 4 hours of yard work, cutting down innumerable branches to appease my home-owners association “warning letter”, and now I have done a couple 5-mile bike-to-work rides.

f962a9cc-5970-419c-9120-88c1acae8860.jpg     af395773-fdca-4e26-8543-7ab262400edb.jpg

Despite my wife’s misgivings, I did not “bonk” or hit the wall on my rides. Maybe my ketogenic diet was actually promoting my fat cells to convert stored fat into ketone bodies for nutrition (the normal non-glucose pathway, I vaguely recall, as I clear the cobwebs from my medical school physiology days). My sustenance has been about 3-4 cups of master cleanse lemonade. I could not convince my wife to smell me to check if my breath was actually fruity (as patients with diabetes who are in severe ketoacidosis exhibit).

Some observations:

Within about 2 or 3 minutes of consuming a master cleanse glass, the hunger disappears rapidly. Hunger is suppressed for 4-6 hours.  Then taking another glass rapidly suppresses appetite again.  I find no decrease in energy.  I find that the hour spent preparing for a regular meal, eating the meal, and cleaning up from the meal becomes just 2 minutes of drinking my lemonade and cleaning a glass (… and then an hour writing a blog about it).  I no longer experience post-meal fatigue and drowsiness.  I think that my mental clarity is actually better throughout the day, and I am forgetting to drink tea as an energy boost because I find I do not need it.

Unlike my perception that fasting would be a miserable starvation experience, this method, that does provide 200 cal in maple syrup 3-4 times per day, is a comfortable, minimal impact to my day.  I am finding that it does not impair my exercise or activity at all.  In fact I am somewhat motivated to stay physically active to prevent any muscle breakdown during this “cleanse.”

It is unclear to me how many days I will persist in this trial.  Each day I find there are challenges as I either smell my wife’s aromatic cooking or observe various family members crunching their way through a delicious meal.  I find interesting moments when I crave a bagel or a piece of cheese, or some takeout Chinese food.

One time, I did consume a ginger candy midway through this cleanse and about 30 minutes after felt somewhat drowsy.  I am wondering if this is a burst of insulin in response to an oral glucose load, causing post-meal sleepiness (see: Post-prandial somnolence on Wikipedia).  Hard to say if it was a coincidence.

Last night in a moment of weakness I rationalized having a bowl of miso soup from a concentrate that I bought at a local Japanese store.  Reading the label carefully, I find that it is only an additional 30 cal of protein and a little bit of carbohydrate.  This was perhaps the most delicious bowl of miso I have ever had in my life.  There is no umami flavor in lemonade.

UPDATE end of day 4. Having braved 4 days of “cleanse”, my cravings betrayed me at last: chips, salsa, miso soup and some cheese and crackers. Oh well, not the end of the world. After four days of consuming only 600-800 calories by way of lemon drink, I figure that’s about 1200 calories net negative each day. My scale did show a drop of 5 pounds over this period of time, with really very little effort. Not sure I noticed any difference in my knee pain (probably a non-inflammatory degenerative arthritis anyway), and my gout is so stable, can’t tell the difference. I did my usual activities, sipped 3-4 glasses of “cleanser” each day, found a surprisingly peaceful, evenly-balanced energy day, felt clear-headed and at least somewhat virtuous. If I was a data geek (ok, I am) I would ask my doc for some lab tests on my uric acid (breakdown product from muscle) and a serum creatinine and electrolytes, to see what is going on inside. Maybe another time, if I end up doing a more extended version someday.

Surprisingly, I found that the first meal after 4 days of a liquid-only diet was an incredible sensory experience.  The luxury of just CHEWING and using my tongue and tasting flavors is a surprising joy when it is no longer a routine.  Maybe that is one good reason to do a periodic fast, the ability to re-discover such simple joys. Oh, the crunch, the flavor, the aroma…

CMIO’s take?  A little bit of fasting may do you good.
Have you fasted before? Let me know!


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