When an ecologic metaphor for health is employed, disease is seen as an imbalance; the work of the physician, nurse, and health practitioner is stewardship; the hospital is part of the ecosystem; and healing becomes part of the process of change, or adaptation. With the wisdom of nature as a guide, the ecology metaphor offers a workable and sustainable approach to health that acknowledges key principles such as: evolution – we are in a continuous, dynamic state of change; interdependence our existence is part of a larger web of life; limits – our resources are bounded, not infinite; diversity – every part of the whole is unique and makes an essential contribution; and cycles – we are part of nature’s patterns and rhythms. (This model is adapted from the Center for Ecoliteracy, 2008.)

I like this metaphor for health and for change because it speaks to fundamental processes that underlie all aspects of our existence. Ecology is the study of the relationships among living organisms and their environments. Ecological systems are driven by evolution – the process of change over time. In the 4.6 billion years since the Earth formed, climates have changed, landmasses have moved, and species have come and gone. Change is our reality.

Ecology as a metaphor for health and healing had deep roots, going back at least to the 1700s, when physician and geologist James Hutton proposed the specialty of “planetary medicine”. Hutton thought species-specific medicine – medical practices dealing only with the human species – was way too small in scope, and that if we don’t take into consideration all else that coexists with us on the planet, we can’t properly diagnose or treat any malady.

The ecology metaphor reminds us we’re all in it together and offers us a chance to come to terms with the transitory nature of health. The whole and its parts must be seen in a “both-and” context, not as an “either-or” duality. Our personal little picture and the larger big picture need to be viewed simultaneously.  Push here, something bulges over there. Pour toxic waste into the sewer, and it shows up in the bay to be consumed in a future seafood buffet. Overgraze a field, and the soil will erode, the crops will fail, the stock will subsequently go hungry, as will the human population.

                Because everything is connected, subtle changes may lead to large disruptions. A tiny plaque in a coronary artery can cause a massive heart attack.  A small embolus lodged in a blood vessel in the brain can result in a stroke, or “brain attack.” A minimal change in water quality or quantity can upset plant and animal productivity and health. Relatedness isn’t confined to a specific location. Our common ancestry and humanity link us over great distances. In a sense, our compassion for the starving in Africa or the sick in India has roots in our shared origins and planetary linkages.

                Every part of the whole matters. Our bodies require a diverse population of cells, tissues, and organs. All are essential to our healthy functioning. Brain, heart, muscle, bone and blood – all must work in concert toward the greater good. Recognizing the value of variation in the natural world can help us value the diversity of human experience, background, culture, race, age, opinions, and solutions. When we are open to multiple possibilities, we find more options on our own path to health. This is holistic medicine; this is deep medicine.

In recognition of Earth Day April 22, 2013

Excerpted from Deep Medicine:  Harnessing the Source of your Healing Power. Oakland: New Harbinger Publications. 2009.             

It is the early part of a new year and the season for personal resolutions related to self-improvement is upon us. It is a time when there is high optimism about really meaning it this year. It is a time when gyms, health clubs, yoga studios, and hiking trails are busy, and new diet plans abound. While more than 50% of those making New Year’s resolutions are confident that they will succeed, only about 10% actually do. In fact, by the first day of spring in March most resolutions are sinking lower on the to-do list on their way to being abandoned all together. Nonetheless, at year’s beginning, many of us annually re-do the resolution ritual. The drive to do so relates to our innate desire to grow, make progress on desired aspirations, dreams and goals, and to improve the quality and quantity of our lives.
Most organizations, companies and businesses, including our own Medical Center, also seek to become more efficient, effective, value-based and successful. Many use a quality development system based on the Toyota Production System. A key part of “The Toyota Way” is characterized by the Japanese word, Kaizen. Kaizen means “to take apart” and “put back together”. It refers to the process of continuous improvement. It depends on repeated “reflection” about strengths and weaknesses and what is working and what is not. The opportunity to improve upon our weaknesses is at the heart of continuous improvement for the organization AND for the individual. Continuous improvement implies openness to life-long learning. Reflection and continuous improvement are at the heart of process and performance improvement for an organization and for personal improvement and self-care for the individual.
The over-arching topic for Deep Medicine 2013 is “Kaizen Within”. When our organizations and systems undergo change, we in the workplace must expect to respond personally to the need to adapt and change. We focus on specific priorities, competencies (strengths/weaknesses) and boundaries, identify what to keep and what to discard, gain new knowledge and learn new skills, make big enough changes to make a difference but small enough to be doable and sustainable, make time for what is really important and insure that we have a “to-be” list as well as a “to do” list. Because in order to do what we want/need to do in the material world of matter, our tasks need to be linked to what really matters.
To borrow a page from Jeffrey Liker’s The Toyota Way, 2004. McGraw Hill, New York: “Toyota’s own internal Toyota Way document talks about the ‘spirit of challenge’ and the acceptance of responsibility to meet that challenge. The document states: ‘We accept challenges with a creative spirit and the courage to realize our own dreams without losing drive or energy. We approach our work vigorously with optimism and a sincere belief in the value of our contribution…. We strive to decide our own fate. We act with self-reliance trusting in our own ability. We accept responsibility for our conduct and for maintaining and improving the skills that enable us to produce added value.’ “
When our world changes we change, and when we change our world changes. The change process needs inspiration and motivation to allow us to begin and perspiration, commitment, value and meaning/purpose to be sustained. Our dreams, callings, desires and passions draw us toward the next horizon. In the end, it is only something that we really want or really don’t want that propels us onward. We need to stretch at the same time we are careful not to overreach and appreciate that our evolution will never be complete. Even in the state of mastery, there will always be another potential milestone or dream waiting to urge us on – and that may be simply appreciating the mystery inherent in where we came from, where we are and where we are going.
What can we each do as individuals this year to enhance our personal/inner and our collective/outer continuous improvement (Kaizen) in 2013??

“That which you are seeking is causing you to seek.” Zen saying

“If you are looking for the greatest treasure, don’t look outside. Look within. Seek that.” Rumi

In Part 1 of “Finding Stability in a Landscape of Change” we looked at the unlikely reality that we will find stability in the ever-changing flux of external events. Rather, we must look within for the treasures of equanimity and appreciate the “do-it-yourself” qualities of this self-directed project. In Part 2, we will review some practical tools to use in the quest for balance and stability.

“If you are looking for the greatest treasure, don’t look outside, look within. Seek that.”    Rumi

Finding stability in one’s life is about learning to be undisturbed when surrounded by disturbance – a challenge which takes many forms, however, is familiar to all in one way or another. The tools for this begin with the pillars of self-care: nutrition; activity (work/service/creativity) /rest; solitude/contemplation; relationship/community. These four pillars occur in various forms in different cultures around the world. Since they also include guidelines regarding ethics, morals, respect, generosity, kindness and fair play, they literally represent wisdom practices, as well as lifestyle skills for self-care and well being.

Where you place your attention is the ultimate power held by each individual. It is through your attention that you bring yourself present in any situation. Choosing to be present in the current moment limits the capacity for worrying about the future and lamenting the past. When you are fully present your choices have the best potential for leading to your preferred view of the future.

Some tools for practicing presence (mindfulness):

*Asking and answering the questions: what am I thinking, feeling, doing at this time? How is it working? Each of these questions will bring you into the present moment. If your thoughts, feelings and actions are working for you and you are in a state of balance and contentment, by all means keep doing what you are doing. If that is not the case, consider letting go of what you are thinking, feeling, or doing and try something different. If that is not possible, ask for help. This practice will also help you realize what is really important, what to add to or take off your plate, what your next best step is, and where meaning and purpose are coming from in your life.

*Tracking what is inspiring, moving, challenging, surprising you at the present time will also bring you from distraction and uncertainty toward currency in the present. Considering these questions requires traits such as honesty, authenticity, discipline, forgiveness, courage, and resilience. Since that is the case, it also stimulates a practice in character development.

*Framing and naming your situation and circumstances appropriately can change your outlook in an instant. Will your hike be on a trail called “morning glory” or “widow maker”?  For your upcoming meeting are you entering a “battlefield” or a “dance floor”? Are you seeing your stress as torture or a teacher? Is your intention to be a victim or victor? Are you headed for breakdown or breakthrough? How you name or title something is an indication of your thoughts and feelings which can definitely affect your behavior and the subsequent course of events. Your attitude and intention have great power to change your world. Practice seeing yourself on a big enough screen in a big enough frame so that your view expands beyond yourself and you gain a context and perspective where your “actual size” is not distorted.

*As long as we are walking in woods, napping on a beach, working in the garden, listening to a babbling brook, and not outside in a hurricane or severe winter storm, Time in Nature will almost always bring you into the present, ease your anxieties, and put you in touch with the beauty, rhythms and magnitude of the natural world as you are reminded of your intimate connection with all that surrounds us. Try to spend some time in nature on a daily basis, even if it is as humdrum as a walk around the block with the dog or watching the sun set. Such time is an amazingly healing balm. Time in nature also provides a chance for a bit of solitude.

*Contemplative time when you can slow down, be quiet and go inward is also a tool that provides us a moment of solitude and releases us from our usual attachment to personal communication devices and busyness. Pray, meditate, listen to music, read from the sages and wisdom keepers, give gratitude, set intention, forgive, breathe and connect with your inner healer.

*Walk, jog, dance, do yoga, tai chi, play, cycle, swim – the best exercise is the one you do!! And the benefits are well documented. So move it!

Whatever you choose to do – be specific, realistic and don’t over-reach. Small steps are doable and can lead to big changes. Don’t bite off more than you can chew – let alone swallow, digest and assimilate. Grand sounding, non-specific goals most often go unmet, while small, repeatable actions become habits as they displace less desirable behaviors. You may find that you need an appointment with yourself to get any of these things accomplished. Schedule these life affirming actions first and make a commitment to them.

A great way to get started is with the daily practice of the “Blessing Way” of Angeles Arrien. I begin every morning with this practice: 1) Set your intentions for the day. This may take the form of a prayer, affirmation, or “to do” list. 2) Give gratitude. There is always something to be grateful for even in the worst of times. 3) Every day perform a “life-affirming action” in the direction of your goals, dreams, longings, passion. This may be as simple as an internet search about something or some place in which you have great interest. However, it is done with the recognition that even the longest journey begins with the first small step. All of these actions are energizing and contribute to the reduction of anxiety and depression as they support general well being.

There are many other tools and practices which support equanimity and the finding of stability in the landscape of change in which we live. Since the best program will be your self-directed version know that it will take time, commitment, discipline, patience and practice to evolve and sustain. Nonetheless, it is doable and the process itself is the reward you are seeking.

“When everything is uncertain, anything is possible.”      Angeles Arrien

Resources:

Arrien, Angeles. 1993. The Four Fold Way: Walking the Paths of Warrior, Teacher, Healer and Visionary. San Francisco: Harper.

Stewart, William B. 2009. Deep Medicine: Harnessing the Source of Your Healing Power. Oakland: New Harbinger Publications.

William B. Stewart, M.D.

“In the Celtic tradition, it was always recognized that if you sent blessings out from your heart, they multiplied and returned again to bless your own life. A generous heart is never lonesome. A generous heart has luck. The lonesomeness of contemporary life is partly due to the failure of generosity,”

                                                                                                            John O’Donohue, Eternal Echoes

“If the only prayer you said in your whole life was ‘Thank you’ – that would suffice.”                                                                                                                                                                   

Meister Eckhardt

Paradox is represented by extremes, dualities, or opposites. In fact, these seeming polarities, such as pain/pleasure, right/wrong, inner/outer turn out to be connected. Giving & receiving/ generosity & gratitude are examples of apparent opposites being inseparable, complementary and coexisting. The giver requires a receiver, just as the peacemaker requires conflict, and a healer requires a patient in order to serve. However, it is a mutually reciprocal relationship not a one-way flow. By giving and/or receiving both the giver and the receiver discover their connection to each other and the “greater good.”

Generosity is freely sharing what you have with others. Being generous means giving something that is valuable to you without expectation of getting something in return. Gratitude is the quality of being thankful and appreciative for what you have received. These are partners not opposites. Both giving and receiving provide the possibility of inner growth and personal transformation for the giver and the receiver.

With his family and legions of volunteers, Nipun Mehta, founder of ServiceSpace (formerly known as CharityFocus) and its DailyGood.org inspirational email message to hundreds of thousands of readers all over the world, has created a global “ecosystem” which generates a “ripple system” of generosity and gratitude of immeasurable impact. “Giftism”, their philosophy of pay-it-forward kindness, involves an “inner shift” which transforms consumption to contribution, transaction to trust, isolation to community, and scarcity to abundance. Each small act of service contributes to a collective wave catalyzing more generosity, more gratitude and keener awareness of the power of each individual contribution to collective consciousness and change. With this paradigm, we don’t necessarily have more, but we discover a sense of interconnection with all that surrounds us, and we want and need less.

The balance of giving and receiving creates a state of abundance. Abundance is not the opposite of scarcity. The opposite of scarcity is greed or hoarding. The state of abundance lies on the middle path between scarcity and greed. This is the path on which givers don’t get exhausted, aren’t overwhelmed or in compassion fatigue. They give until it feels good not until it hurts. It is the place where receivers maintain their dignity as humans, their self-respect and their hope. And all recognize that we are in a dynamic flow where we are continuously in both camps: generously sharing what is valuable to us and giving gratitude for all we receive. This state of balance and wholeness defines well-being. When in balance, generosity & gratitude and giving & receiving are good for your health!

Each of us has something to be grateful for, not only our blessings but also our challenges. Every challenge is an opportunity to grow and to change, a chance for creativity to emerge, and to move beyond what is known and comfortable. Practice giving gratitude – speak it, write it, listen for it, do it. A gratitude unexpressed is like a gift unopened. Each of us has something to share and to give – our time, our talents, our treasure, our care and compassion, our understanding, and our love. These gifts are “medicine” for those they touch and for those who provide them. Underlying generosity and gratitude is an inner transformation which influences outer change.

What do you have to give at this time? What are you grateful for at this time?

“As we grow in spiritual consciousness, we identify with all there is in the world. Then there can be no exploitation. It is ourselves we are helping. It is ourselves we are healing.”

                    Dr. G. Venkataswamy (Dr. “V”), Founder of the Aravind Eye Care System, India (1918 – 2006).

Resources:

Mehta, Nipun, “Generosity 2.0”. Kosmos Journal. Nov. 2009.

Arrien, Angeles. 2011. Living in Gratitude: A Journey That Will Change Your Life. Boulder: Sounds True.

Emmons Robert. 2007. Thanks: How the New Science of Gratitude Can Make You Happier. New York: Houghton Mifflin.

O’Donohue, John. 1999. Eternal Echoes: Exploring Our Yearning to Belong. New York: HarperCollins.

“No external experience will support us because the flux of events is inescapable.”

Alan Watts, The Wisdom of  Insecurity

“…our grace comes from owning the risks we take in a world largely immune to our control.”

Rosamund and Benjamin Zander, The Art of Possibility

There presently is a tsunami of change sweeping over healthcare. This wave of change involves all of us – whether well or ill, patient or healer. This particular example of the play of change in our lives involves the full spectrum of individual and collective well-being from laws of the land to our institutions, organizations, and personal circumstances. Since it is our nature to prefer the known to the unknown and stability to chaos, change, whether welcome or unwelcome, is stressful. Change is associated with uncertainty and uncertainty with insecurity.

Enduring stability cannot be found in our ever-changing material world. The reality is that impermanence, uncertainty and insecurity are part of the natural state of our lives. We exist in a constant dynamic flow: growing, regenerating, learning, aging, evolving. We never really know what is coming around the next corner, what the next moment will bring, or how things will ultimately turn out. For example, consider the existence of “blessings in disguise,” or the proverbial “cloud with the silver lining.” Much comes to us uninvited and outside our locus of control. The Dali Lama has said that events outside of our control should be no cause for worry, since we can’t do anything about them. What about those situations over which we do have control? Well, if we have control over them, we certainly have no need to worry about them! In theory there actually is nothing to worry about! Then why do we spend so much time either lamenting the past or worrying about the future? Very simply stated it is because we fear the unknown and for the most part, we don’t like surprises. We would like to make our existence stable, balanced, and predictable – whether we are on our morning commute or a joyride on a roller coaster. However, no matter how hard we try, how much data we assemble, there are real limits to our capacity to predict anything from the weather to what our children will be/do when they grow up, to the time and circumstances of our death. Facing this reality with equanimity is our challenge.

In this landscape of change, where do we find stability? Two intersecting avenues support our quest for stability: the discovery and exploration of our inner world; and developing the skill set of being non-judgmentally in the present moment, often called mindfulness.

“What lies behind us and what lies before us are small matters compared to what lies within us.”

                                                                                                                 Ralph Waldo Emerson

“It is the work of all human beings to attend to the health of both their “inner” and “outer” house: the “inner house” of the limitless world within, and the “outer house” of the material world in which we live our daily lives.”

                                                                                                                  Angeles Arrien

While we use search engines daily, the search of our expansive “inner house” requires us to look within toward that part of our existence which, like an iceberg, is not always visible. We are far more used to directing our interest outward, toward the next big, necessary or new thing clamoring for our attention, rather than inward toward the changeless, eternal reality underlying our visible world. But it is the inward search that we must institute if we are to find stability. To discover this inner world requires that we choose to pay attention, slow down, and get quiet. Not easy tasks in our fast lane, fast food, constantly connected world. However, if we don’t make these choices we will deny ourselves the opportunity to ask the most meaningful questions, enable ourselves to hear the wisdom from within, and then choose to act accordingly.

“Control of attention is the ultimate individual power.”           David Brooks

“You must be present to win.”                          Source unknown

Are you living in the present moment? Are you paying attention to where you are, whom you are with, and what you are doing – right now? Or are you time-traveling to the past or the future? It is important to know, for it is only in the present that you have the possibility of making the choices which have the greatest potential to lead to your equanimity and your preferred vision of the future. Where we choose to put our attention – to which thoughts, feelings, and actions we attend to; to which attitudes, perspectives, expectations, stories we carry; toward which companions we surround ourselves with; how we spend our time; and to when and where we choose to fully show up – determine how we contribute to the creation of our lives. Our attitudes can trump our diagnoses. We can change the stories we repeatedly tell ourselves. We can define and act on what has meaning, purpose and value in our lives.  Our ability to pay attention to what is actually happening now, in the present, is essential to discovering stability in our busy lives. Our capacities to choose and change in the dynamic landscape in which we exist provide constructive action steps in the direction of harnessing our inner power in support of our balance and equanimity. Our stability ultimately must come from within. It is an “inside job” not a function of our external world. The past and the future are in our imaginations. The present is our only reality and to be aware of this is a true gift. To paraphrase a French proverb in the words of Kung Fu Panda: “Yesterday is history, tomorrow is a mystery, that’s why today is called the PRESENT.”

In anticipation of Part 2 of “Finding Stability in A Landscape of Change”, pay attention and track for yourself the following questions suggested by cowboy/psychologist Wyatt Webb on how we go about practicing being current with ourselves and in the present: What are you thinking? What are you feeling? What are you doing about it? And how is it working? In Part 2 we will engage how to practice presence and build equanimity and stability into our daily lives.

Recommended Readings/Resources:

Arrien, Angeles. 1993. The Four Fold Way: Walking the Paths of the Warrior, Teacher, Healer and Visionary. San Francisco: Harper.

Mehta, Pavithra & Shenoy, Suchitra. 2011. Infinite Vision: The World’s Greatest Business Case for Compassion. San Francisco: Berrett-Koehler.

O’Donohue, John. 2008. To Bless the Space Between Us. New York: Doubleday.

Stewart, William B. 2009. Deep Medicine: Harnessing the Source of Your Healing Power. Oakland: New Harbinger.

Tan, Chade-Meng. 2012. Search Inside Yourself: The Unexpected Path to Achieving Success, Happiness (and World Peace). New York: Harper Collins.

Watts, Alan. 1951. The Wisdom of Insecurity: A Message for An Age of Anxiety. New York: Penguin.

Webb, Wyatt & Pearlman, C. 2002. It’s Not About the Horse – It’s About Over-coming Fear and Self-doubt. Carlsbad: Hay House.

Zander, Rosemund Stone & Zander, Benjamin. 2000. The Art of Possibility: Transforming Professional and Personal Life.  New York: Penguin.

Contemporary biotechnical medicine is a relative newcomer to the arena of healthcare. Our present allopathic approach to diagnosis and treatment of illness owes a great debt to the scientific method and to ancient and timeless approaches to healthcare from around the world.

Ayurveda (the ancient medicine of India), traditional Chinese Medicine including acupuncture, shamanic practices of indigenous people, and folk medicines from various cultures have oral and written records dating back thousands of years. More recent systematic approaches such as homeopathy, osteopathy and chiropractic have paralleled the development of allopathic medicine. As other systems of medicine are becoming more widely understood and applied, the boundaries of medical practice continue to grow.

Medicine is truly a “practice” which requires lifelong learning and continuous improvement as new knowledge becomes available and old knowledge is rediscovered. Embracing both – new biotechnical, pharmacologic and genetic advances and our healing heritage – has the potential to strengthen contemporary medicine and expand the possibilities for healing. This will lead healthcare practitioners to improved clinical diagnosis and treatment, and a greater appreciation of and compassion for the experience of illness.

The Moral of Morale

William B. Stewart, M.D.

In this month of independence (July), I have been asked to talk/write about “morale”, particularly in the workplace.  Keeping with the season, I am going to exercise my independence by writing about interdependence and connection in the context of morale.

Morale is defined as a mental or emotional condition which is expressed via such qualities as confidence, optimism, motivation, cheerfulness – a can do spirit – or lack thereof. These traits are particularly desirable, and often found missing, in the face of challenge, opposition, hardship, conflict, etc., e.g.  prior to the battle, the morale of the troops was high. Generally, like safety, which is about doing everything so that nothing will happen, we are most concerned with morale when it is low, lost or absent.

It should not be surprising that the word morale is closely related to the word moral. Both words come from the same Latin root. Moral is defined as pertaining to rules of right conduct. That is the distinction between right/wrong, good/bad, honorable/dishonorable. Words used to describe or define moral  include honest, upright, virtuous, as well as words used to define morale such as confident, optimistic, open. These descriptors refer not only to proper behavior in a collective or society, but also are concerned with character or temperament.

Moral, as a noun, relates to a lesson from a fable, story or event; and to a concise truth. The Greek translation of moral is “ethics”. So morale, moral and ethical are all related and refer to qualities and behavior considered valuable and virtuous.

The causes of low morale at work are also the common reasons that people usually leave a job. Often, low morale is blamed on leadership. While it is true that a bad relationship with a direct supervisor is one of if not the most common cause of someone leaving a job, that is only where the list begins. Insufficient attention to the physical needs for satisfactory working conditions from décor to noise to light and ventilation affect morale. Lack of opportunities for growth, no sense of purpose or direction, an uninspiring vision, work that does not feel meaningful – these all contribute to dissatisfaction and low morale. Work which does not provide decision-making responsibility or authority and is short on recognition and rewards will not be work that builds morale. Gossip, rumors, character assassination of people, departments and/or the organization will kill morale; as will constant criticism not attached to suggestions to solve the problem being complained about.

Often forces well outside of our influence and control will impact our circumstances at work. These include natural disasters;  global, national and local economic and political disturbances;  bad luck and the mysterious interplay of fate and destiny. Let us also recognize that many people don’t like their work, are unhappy, do not feel engaged or empowered and are in wrong placement. Individuals need to accept some responsibility for their joy and/or discontent with their work, and the impact that has on the morale of a group. There is a strong inherent urge in humans to connect with others. Their relationships with individuals, family, small and large groups; their work; their health; and to what constitutes “enough”; as well as their connection with the creative unfolding of the world in which we live will all affect morale. In this way, morale begins with each of us. While we often have little effect on changing others, we can have dramatic effects on changing ourselves.

Can we change morale? The answer, of course, is yes! If we are coming from a place of possibility, are open to change, and not stuck in a place of rigid “positionality”.

“A person is but the product of his thoughts. What he thinks he becomes.”     M. Gandhi

How then might we go about impacting morale in a positive way? This can occur as an “external job”, i.e.  changing the environment – physical and otherwise. For morale is affected by the décor, by people’s demeanor, through the frequency and form of communications in an organization, and by the “culture” of the collective (more about “culture” at another time).  Each of us through our attitudes, beliefs, values and actions are contributors to the collective morale by way of our personal morale. Therefore, morale building must also be an “inside job”.

“if you want to change the world, first change yourself. When you are changed, truly changed, the whole world will be changed.”                                                                         Sri Aurobindo

In their accessible and inspiring book, The Art of Possibility, Ben and Rosamund Stone Zander describe practices to grow personal and professional meaning and fulfillment by moving us into the morale-building world of possibility. Three of their suggestions are touched upon below.

1)      Dare to dream – create an inspiring vision where the force of possibility dominates. A vision that is timeless, universal, and to which almost anyone can relate. Then embody that vision. That is what Martin Luther King did with his “I have a dream” oration and his actions in the world.

2)      Expand your playing field – we tend to see our lives as being played out on our own small personal TV/cell phone/movie screen. After all, we are the writer, director, producer and star in our movie. Practice seeing yourself on the largest/widest screen possible. A playing field at least the size of a golf course, rather than, for example, an indoor basketball court. On a golf course the playing field is gigantic compared to the size of the target hole. While it is quite possible to be out of bounds, it is at the same time difficult to stay in the fairway. Furthermore, wherever the ball lands be it fairway, rough, hazard, trap you have to play it or take a penalty. Since you and the circumstances are never the same, you never take the same shot twice. Furthermore, the game goes on despite the weather, economy, or politics of the moment. When we see not only ourselves but all that surrounds us including circumstances beyond our influence or control – such as heavy traffic, bad weather, the action of others in our immediate environment (opponents AND team mates ), bad luck, even fate and destiny as part of the playing field, then in words from The Art of Possibility , “…grace comes from owning the risks we take in a world by and large immune to our control.” When it all becomes part of our personal world,  then through our constructive thoughts and emotions, words and deeds,  we need not feel victimized or hopeless because we actually do have influence over how we respond to whatever arrives at our gate.

3)      Change the frame – “A pessimist sees the difficulty in every opportunity. An optimist sees the opportunity in every difficulty.”                                                                W. Churchill                                                                  

Are you seeing the glass as half full or half empty? Are you focusing on what is working or what is not working? Are you giving more attention to the low performers or high performers? Are you laying bricks, building a wall or creating a cathedral? Are you attending to those things that you can influence and change or to those things you have no control over?

Through your thinking, words and actions be mindful of creating frames for your picture of reality that foster creativity and possibility. In so doing, your “moral” compass will be true and the “morale” around you will be high.

Resource:

The Art of Possibility: Transforming Professional and Personal Life by Rosamund Stone Zander and Benjamin Zander. Penguin Books, New York. 2002.

The Work of Healthcare: Back to the Future

William B. Stewart, M.D.

As we engage the topic of work during 2012, it might be interesting to imagine what the work of healthcare providers might look like in the not-too-distant future. In the USA, the cost of healthcare continues to rise. The proportion of GDP devoted to healthcare expenditures has more than doubled in the past 25 years. Nonetheless millions of people remain uninsured and underserved. As this is being written, debate over President Obama’s federal healthcare plan continues and a Supreme Court decision on its constitutionality is pending creating significant uncertainty among all concerned. Compared with many other countries, our health outcomes are not proportional to the amount of money we spend annually per citizen on healthcare. Furthermore, there remains room for improvement with our approach to health and illness related to access, safety, quality and satisfaction.

Looking at an issue of the magnitude of health requires invoking both the reductionist and holistic philosophic approaches. One school, the reductionist, contends that you cannot understand the whole without knowing its parts. The other school, the holistic, teaches that you cannot know the parts without understanding the whole. As is the case with most profound truths, each statement is true and its opposite is also true. Therefore, to imagine the future of healthcare we must be both reductionist and holistic. Because of the complexity and variables involved, we must look to the microscopic and the macroscopic; the cellular and the cosmic; the high tech and the high touch; and the personal and the public.

It is not enough to consider the specific inciting agents of a disease or a focused treatment of that disruptive agent without appreciating the milieu in which the disease found a place to take hold. Wellness and illness exist on a dynamic spectrum. In their earliest stages most diseases are without obvious symptoms or detectable signs to even the most learned practitioners and most sophisticated diagnostic studies. Nor is one’s health the domain of teams of experts or the biotechnical alone. Health creation is an “inside job” and requires the active participation of the individual. We cannot simply farm out our well-being to experts or surrogates.

In fact, there is no issue that does not affect our well-being. Every issue is a health issue. Physical status, emotional states, absence of meaning and purpose, inadequate housing and education, toxic environments, poverty, violence, as well as lack of family or social support are all health risk factors – and only a partial list of what impacts the status of our health and well-being and the outcome of our illnesses.  The specific signs and symptoms of wellness or disease are merely the tip of the iceberg.  What underlies these “visible”, measureable markers of health/illness include our behavioral, lifestyle, physical, mental, emotional, philosophical, spiritual, social, environmental, economic, and geopolitical realities. Furthermore, they are all interconnected like the ecosystems in which we live. From gene pool to organ systems, medication to meditation, family to culture, village to nation, watershed to biosphere, planet to cosmos — the Earth can no more survive separated from the sun than the body from the heart, or the individual from the collective.

The juxtaposition of the reductionist and holistic approaches brings us to where we find ourselves today in the arena of healthcare. Running out of money; probing our ultimate uniqueness via elaboration of the human genome; mining the riches of technology with devices that can define us and connect us in an instant and gather and collate unimaginable quantities of data while doing so. At the same time, people are seeking a less invasive, less expensive, more humanistic and relational format for healthcare. This desire is seen in the growth in popularity of complementary, alternative, integrative and holistic healthcare. Compared to contemporary high tech medicine, these high touch practices tend to emphasize the power of wellness-promotion, illness-prevention and self-care rather than the treatment of end-stage disease. They emphasize health-creating choices regarding nutrition, physical activity, rest and relaxation, creativity and work, relationship and community, and reflective and contemplative practices. These practices are proactive, preventive, personal, and participatory. They require the active engagement of the individual and initiating action even in the absence of signs or symptoms of specific disease states.

As these high touch, high tech approaches are coordinated they hold the capacity to enhance prevention, diagnosis, treatment and most importantly – quality of life. They hold the possibility to better define and measure biological markers, be they genetic, biochemical, electrophysiological or another yet-to-be-developed “vital sign”, or something as simple and commonplace as weight or blood pressure. They have the potential of being predictive for the individual in a very personal way. Have population studies demonstrated the individual’s findings to be indicative of an impending disease at a very early stage? Should s/he continue on the same path or is a change needed based on the gathered personal longitudinal data?  Is there a specific, focused treatment, compatible with the individual, which can be instituted to prevent the progression of the disease beyond this early state?

In Ayurvedic medicine (the classical practice of medicine in India) and traditional Chinese medicine, the “constitution” of the individual is determined and treatment tailored to the patient based primarily on thorough history-taking, physical examination, and an on-going relationship with the patient, his/her family, and their community. Because of the personalized approach of these systems of medicine, even people of similar age, gender and illness are likely to receive different treatments because of their unique needs. Contemporary Western medicine via its scientific, reductionist pathways is at the frontier of developing the tools to further refine such ancient empirical approaches through the marvels of modern science and technology. Will future versions of our ubiquitous cell phones be the devices to take and record personal biologic measurements? Will comprehensive genetic and blood analyses and advanced data collection and management replace today’s more limited laboratory testing, setting the stage for sequential monitoring over time and early targeted treatment intervention when deviations from the established norms are detected? Will outcomes then improve? Will this individualized biologic and data driven approach free up more time for the highly desired person-to-person interaction that defines “personalized” care in the holistic and interpersonal  way rather than the scientific reductionist way? Will integrated teams in “patient-centered medical homes” dealing with multidimensional personal and social health determinants be the next preferred healthcare delivery model across the lifespan?

There is a revolution going on in healthcare. It is not confined to debates in Congress or to decisions of the Supreme Court.  Nor is it about purely economic considerations.  It is about the true meaning of health and healing and the moral, ethical and compassionate principles and values of the practice of medicine. It is about how we can best utilize the human and other resources available to us to create individual well-being, the public health, and planetary healing. The potential for improving the health of the Earth and of those travelling upon it is monumental. We are each healers with unique medicine to contribute to this worthy work.

Resources:

Hood, L. and Flores, M., “A Personal View on Systems Medicine and the Emergence of Proactive P4 Medicine: predictive, preventive, personalized and participatory”, New Biotechnol, 2012, doi:10.1016/j.nbt.2012.03.004.

Morrison, Ian, “Massively Coordinated Care”, H&HN(Hospitals &Health Networks) Daily, May 1, 2012, http://www.hhnmag.com.

Dear Friends,

Gratitude for another richly inspiring call this past Saturday! Our guest speaker, the surgeon turned Integrative Health pioneer, Dr. William Stewart (fondly dubbed “Dr. Uncle Bill” by the ServiceSpace community!) riveted listeners from the very start with an eloquent explanation of “Deep Medicine”. The title of his fascinating book, and a phrase that conjures up the mystery of healing, and a conviction that it arises not just from the mind but the innermost recesses of the heart. “There is no issue that is not a health issue,” he boldly declared. Retracing his journey, this born healer delighted us with stories of his preschool days spent ‘tending stuffed animals and stepped on grasshoppers’, awed us with operating room tales from his days as a renowned oculoplastic surgeon, and moved us with stories of the ‘instantaneous experience of humility’ that he walked into while serving with Dr. V and the Aravind Eye Hospital in India. Sprinkled throughout his reflections were profound and practical insights on what it means to commit to a planetary medicine that truly heals both us and others: “We understand ‘care’ but we don’t really understand ‘self’ very well”.

Stay tuned for Bela’s recap of the call. In the meantime, for those interested, here’s the full audio recording. If you’d like to learn more about Dr. Uncle Bill’s work you can visit the Institute for Health and Healing website, browse through his personal blog or look through his wonderful book. And if you’d like a glimpse of his eloquence in action, here is a link to a beautiful speech he recently delivered in India.

Saturday’s call was twice blessed, by a moderator who is yet another shining star in the field of medicine. Dr. Sriram Shamasunder — the beloved doctor-poet whose compassionate work regularly takes him into some of the most impoverished areas of the world. For those unfamiliar with his work, here’s a DailyGood on Sri that we ran a little while ago.

And the inspiration train continues to continue! Here’s a sneak peek at next week’s speaker: Nimesh Patel — better known as Nimo — the gifted artist-musician who traded in celebritydom for a one-of-a-kind service journey that all began with a bright-eyed band of children in the slums of Ahmedabad. Next week, he along with sixteen of these children will fly across the globe on a world tour with Ekatva – a remarkable dance performance dedicated to the spirit of Oneness. A performance that was two incredible years in the making and that could not have gotten this far without an unflagging commitment to inner transformation. To RSVP visit http://ijourney.org/forest

With gratitude for the deep medicine of these calls and the community they foster.

In service,

Pavi (on behalf of the magnificent “Forest Farmers” Bela, Bill, Nipun, Kanchan, Rahul, Amit & Audrey)

–
If stories come to you, care for them. And learn to give them away where they are needed. Sometimes a person needs a story more than food to stay alive. – Barry Lopez

“The Proof of the Pudding”

William B. Stewart, M.D.

It is a well known and often heard saying that “…the proof of the pudding is in the eating.” However, in fact, it is in the digestion and assimilation of the pudding, not simply in the ingesting, wherein lies the proof or value of the pudding. Often what looks, smells, and even tastes good to us is not necessarily what is actually “good” for our health and well-being. What we “want” may not actually be what we “need”.  Sometimes we actually bite off more than we can even chew. You can’t tell a book by its cover, good things come in small packages are other common sayings which remind us that things, in the final analysis, are not necessarily what they seem initially. Until we really get into something or it truly gets into us we just don’t know. Time is needed to digest, absorb, assimilate, and integrate experiences. From an exotic meal to an unfamiliar environment to a new group or behavior, we need to process, or to use a more medical word “metabolize”, that to which we are exposed  before we can fully assess its value and impact. Whether the new recipe will ultimately cause us agony or ecstasy – at the time of eating – is uncertain.  Sometimes we bite off more than we can chew, sometimes our eyes are bigger than our stomachs, sometimes even too much of a good thing is not a good thing, and some things no matter how sweet they seem will simply not agree with us.

In the fall of 2011, my wife and I spent two months in India where we worked, consulted and studied. Although we had been to India many times before, this trip was of longer duration than usual, during a hotter time of the year, to places familiar and new, with dear, old friends and many people and destinations  we had never encountered before. We returned to home and family during the long Thanksgiving weekend and I promptly returned to work at the Medical Center the Monday after Thanksgiving. Until someone asked me “How was your vacation?” I hadn’t realized the impact our travels to India had had on me. Yes, I had been away in an exotic part of the world. However, the word “vacation” in no way captured the essence of our experiences.  It was then that I appreciated that a significant part of what I had “ingested” in India remained undigested, incompletely metabolized and unassimilated.

Although my physical body had returned home on the Thanksgiving weekend, it has taken me more than three months, a season really, to begin to digest, assimilate and integrate my thoughts, feelings, and changes with my “real” daily life and “regular” work world. This integrative process is a creative activity and as such it requires work. This personal work of integration takes quiet time and introspection. These are two activities which are conducive to the winter season, however, not conducive to the “busyness” of one’s everyday life. Personal “inner” work also requires focus and discipline to differentiate the wheat from chaff and to know what to keep and what to discard. This particular work, I hope, explains the hiatus from contributing to my usually monthly Deep Medicine blog, to which I am returning with this entry.

During this formative period of “metabolism”, I have suffered and benefitted from “writer’s block” or some related syndrome. Nonetheless, during my season of integration, a small pamphlet, “A Year of Deep Medicine”, has been published containing 12 adaptations of talks presented to clinical and administrative staff at California Pacific Medical Center, San Francisco during 2011 under the year-long theme of “Everybody Makes a Difference”. These talks make up the heart of my Deep Medicine blog. In 2012, a similar series of talks will occur. This year the overarching topic is “Working Together”.  Adaptations of these presentations will also be posted as blog entries.

Work manifests our creativity, productivity and connectivity. It can be dream-come-true and/or drudgery. It takes many forms from job to calling. Our “true” work puts us in touch with ourselves and with others, not just at the level of personal interaction, but in the sense of service to the community. Work is one of the most significant health-related activities there is. Whether working, over-worked, addicted to work, resting or recovering from work, underemployed or unemployed, work can be agony or ecstasy and often is a source of stress. We are all familiar with the multidimensional impact that stress has on our bodies, minds and spirits. At the same time work also provides purpose, meaning, contribution and fills our needs for sustenance, connection and survival.

During 2012, we will engage issues such how we are influenced by work being at the center of our adult lives; how it benefits and burdens us; and how our personal/”inner” work relates to our work in the world. I hope that you will join me over the coming months of 2012 in this exploration of work.