Flow

Photo by Solen Feyissa

A body at rest will stay at rest unless acted on by an external force. Likewise a body in motion will stay in motion unless acted on by an external force. This principle of inertia, as paraphrased from Newton’s first law, has many parallels with human motion, with human activity, as well. There is an energetic cost to enter any meaningful activity. This cost is analogous to shaking off the dust or warming up. Getting to the point where things are moving smoothly, a point where one falls into a natural rhythm takes time. There is no way to get rid of this warm-up period. Understanding this buy-in, the time sink required at the beginning of the activity, is critical for designing the day productively. 

Activities such as running require a period of acclimitization until one begins to feel the rhythm in their legs and their breathing begins to smooth. Initially every step is an effort, often the jolt of the road or track is jarring and unpleasant. But over the next several miles the collision of the foot and the ground becomes more fluid, the blood redistributes to key muscles and organs, and the mind begins to fall in line with the new rhythm. After two or three miles the mind slowly clears allowing focus on a single thought. The same is found in swimming where the a rhythm must be found that aligns with the movement of the water, a coordinated dance between the strokes, kicks, and breaths. It is critical to embrace this buy-in period, to push through this warm-up to get to the flow state. Too many workouts end just after the flow state is established. At least during a workout, the benefits to the cardiovascular and muscular skeletal system are still won during the warmup period. In other activities the buy in period is simply a period of time of low objective productivity, a preparatory period for things to come. 

Writing, true writing, not just putting words on a page, but communicating a complex idea with clarity and simplicity in a relatable and integratabtle fashion, is a difficult task to do well.  There is a high buy in cost in that there may be an extended period of time at the beginning of writing where there is little productivity as ones mind begins to craft arguments, meld world into sentences, and smooth sentences into paragraphs, all with a unifying theme. Writing, like coding, or complex data analysis, is difficult to pick up with small pieces of time. Writing with five minutes here or there will take longer and leave a worse product that writing in dedicated blocks of time. The cost of writing is then the exclusion of distractions for extended periods of time. 

The flow state, regardless of activity must be protected. Once this flow state is achieved, there should be few things, if any, that takes one from the flow state. The productive day should be designed around achieving and maintaining these flow states at predetermined times. One final cost of buying into the flow state bears mentioning. There are days, sometimes even weeks or months where the flow state is hard to achieve, where every foot strike is a physical and mental effort, where every sentence is achieved more with perspiration than inspiration. And that is okay. That is part of the game. That is part of life. There will come a time when the flow state comes easily again, and it will have been worth all of this effort.

Be purposeful about achieving flow. 
Guard the flow. 

Anti-Frenetic

Photo by Joshua Fuller

“At a cardiac arrest, the first procedure is to take your own pulse.” This oft quoted line from House of God is not unique to medicine, but applies across a wide swarth of life. The first question to ask when approaching an emergency is assessing the area for safety. Nothing turns a bad situation even worse as quickly as increasing the number of patients and decreasing the number of providers in an instant. After that, only two things are critical within the first handful of seconds. The first is to call for help and make sure that more assistance is on the way. The second is initiation of high quality CPR to keep key organs such as the brain perfused. After that keeping your own heart rate low, your mind clear, and your attention on the task at hand becomes the only concern. 

For teams that are well versed in running these codes there is often a feeling of calm, a rhythm that is rapidly ensues. Each person knows their role, the basics are covered with such precision that higher level thinking including methodical consideration of the underlying physiology can be done as the basic algorithms are already covered. The first time doing chest compressions, one of the attending physicians pulled out a pocket metronome to help me keep pace. For teams that are less familiar with codes or are not consistently working with high acuity patients, there is a frenetic pace to the code. A feeling of rapid movement, albeit with little forward motion, is tangible. Often very specific directions must be given to delegate tasks, ensure that proper medications are given, and to keep everyone on the same page. The frenetic activity results from the feeling of panic that those arriving may feel and the desire to do something, to do anything. 

Frenetic activity is the default. Often it even feels good. Activity provides a distracting sensation. In less urgent situations pacing, tapping on the desk, or other manifestations of frivolous activity may be permissible. In the situations which truly count, this frivolous activity is unacceptable. Steady hands and clear minds are inhibited by background motion and good communication is broken down by the cacophony of background noise. 

Rejecting meaningless motion, high paced but trajectory less activity, is essential. Being anti-frenetic in these moments is a choice, plain and simple. An anti-frenetic attitude does not mean that one is confident that a good outcome is guaranteed or that a serious problem is not present. In many cases a good outcome is far from guaranteed and a serious problem is definitively present. Freneticism is the antithesis of communication, teamwork and progress. Being anti-frenetic means recognizing that panic, high velocity flailing, is of little value and that the best chance for a good outcome is rejecting fear and the sensation of panic welling up in ones throat and choosing purposeful, meticulous activity with good communication and an emphasis on teamwork. 

Take your own pulse. Reject fear. Suppress panic. Do your job. 

Options

Photo by Jeremy Bishop

There are few things as daunting as endless choices and open opportunities. This is the struggle of a writer staring at a blank page. This is the struggle of a sculptor gazing at a block of marble. This is the conundrum of the undecided college major. On a much shorter time scale, this is the dilemma encountered when deciding what to eat or what to do on a day off of work. 

Options may be initially comforting. Having options provides the illusion of freedom in that if one does not like the current choice or selection one is able to bail on plan A and pursue plan B. Subsequently, if one finds plan B not quite to their taste, they will have no qualms about opting for plan C. As soon as there is a bump in the road with plan C, have no fear, there is always plan D. While some options may be beneficial, flitting from one option to another is the antithesis of digging deep, of going for the long haul, of feeling the struggle and ultimately the reward of any specific option. Freedom, true freedom, is not endless choices but enough agency to select and pursue a path of meaning and value. Collecting options, more often worded as “keeping my options open”, is similar to collecting happy meal toys. The options themselves are not useful in the long term, new options are constantly coming out, and in a matter of months, the options will be revert to being valueless. The freest life, the good life, then is not having infinite options but having a meaningful trajectory with the ability to navigate and steer through the obstacles ahead to a better destination. To achieve this, a flight plan, a structure is essential. 

Structure is freeing. Routine is comforting. Building independent structure is absolutely essential. When interviewing for medical school one of the common refrains was, “50% of what you will be taught in medical school will be wrong by the end of your career. The problem is no one knows which 50%.” The move in medical schools has broadly been away from teaching only discreet pieces of knowledge, facts and patterns, and towards learning how to incorporate new findings and studies into one’s clinical practice on an ongoing basis. Instead of having facts and figures spoon fed from lecturers and text books (have no fear, there are plenty of those still), there is a growing emphasis on how to ask questions, find new knowledge, evaluate the validity of new findings, and then incorporate those findings into clinical practice.

Broadly speaking, the goal is to learn more medicine. Yet that is both broadly intimidating and unhelpfully nonspecific. Instead an outline of what one hopes to gain, a question that one would like to explore must be defined. The process of recognizing weaknesses and working, in an organized and deliberate manner to turn them into strengths is always ongoing. Instead of “learn more medicine” a desire to learn more about the heart must be further refined into defined questions and goals. Instead of “learn more about the heart”, actionable goals could include “recognize patterns of ischemia on EKG” or “review the treatment of acute presentations of myocardial infarction.” The blank page of “learn more medicine” must be refined into a far more specific and useful structure for progress to be made. 

Structure to freedom 

There Is Always Something

Photo by Ethan Dow

There is always something. 

There is always something to be unhappy about. 
There is always something that could have gone better. 
There is always something that could be optimized, a more ideal way. 
There is always another option, something else that could be tried. 

There is always something. 

There is always more. 
There is always the next thing. 
There is always newer. 
There is always an upgrade. 

There is always something. 

There is always work to be done. 
There is always a project due.
There is always money to be made. 
There is always a deadline ahead. 
There is always a raise or promotion to be had. 
There is always a prize to be won. 

There is always something. 

There is always a faster mile to run. 
There is always a heavier weight to lift. 
There is always another race. 
There is always more fitness. 

There is always something. 

There is always a larger house. 
There is always a faster car. 
There is always a better phone. 
There is always a nicer vacation. 
There is always finer food. 

There is always something. 

There will not always be long conversations into the night. 
There will not always be lazy mornings around the kitchen table. 
There will not always be the familiar pot of coffee or the light on the porch. 
The chairs will not always be filled. 
The phone calls will not always be answered. 
Familiar disruptions will not always disrupt. 

There is not always someone. 
But there is always something. 

Choose Your Grind

Photo by Dinker Gulati @dinker

Often difficulty lies not within the task or struggle itself but is a function of the inability to select the time, place, and duration of that struggle. Nearly any task, even the most benign, becomes a significantly greater struggle when done at an unpredictable time in the middle of the night. Running 5 miles in the cool of the morning or jogging along the water as the sun sinks below the horizon are radically different experiences than being pushed out of bed and forced to run any distance in the middle of the night. The former is good fun and enjoyed by millions daily, the later usually reserved for training camps. 

There are times in life during which a good hard grind is requisite, when there is nothing else that can be done but to put ones head down and push.  Scenarios in which no previous effort or planning would have lessened or removed the necessary grind. Yet for most scenarios in life, the grind is fungible, that is the grind is transferable, interchangeable, both in duration and form, for another grind. The simplest exchange is that of duration. Some grinds, such as writing documents, performing experiments, and preparing presentations can have the high intensity deadline grind, sometimes all of the unpleasantness altogether, removed simply by planning early and working diligently- the very principle that parents and teachers attempted to imbue from the early years of schooling. Other grinds can be exchanged completely. 

Money is the medium by which the world exchanges grinds on a daily basis. Instead of spending time working on a variety of tasks such as growing food, making clothing, building a house, and inventing new things, these very different grinds are exchanged through the medium of currency for whatever grind suits ones fancy and expertise. This specialization allows one to pick something they find relatively enjoyable and attempt to trade the grinds that they either find unpleasant or for which they lack the technical skills or expertise. 

While this exchange certainly works for the common things such as food, clothing, and houses, the same exchange can be used for many of the other grinds including cleaning, transportation, working out, home repairs, moving services, and errands among many others. The struggle often lies within the inability to choose the grind, not the grind itself. 

The ability to choose the time, place, and type of the grind is an enormous privilege, one that historically has been available only to a small number of elite. The grinds previously were fixed, difficult to switch, and often required for survival. With specialization, the ability to hone and perfect a grind, came with it a newfound pleasure in that grind. There is a joy to excellence, in a job well done. There is an enjoyment that comes with mastery, with the fine craftsmanship that is only found with experience and repetition, the natural outcome from being able to choose a grind.

Choose your grind.
Perfect your grind.
Enjoy your grind. 

The Problem of the Pedestal

Photo by Ricardo Gomez Angel

In the iconic scene from the Dead Poet Society, Robin Williams encourages each of the students, members of the class to take their turn standing on top of the desk. One by one each pupil files up to the front of the class, stands on top of the desk, and looks out at the world from atop their new perch. The purpose of this exercise is to gain new perspective, a new view on the world. Instead of viewing their world, in this case the classroom, through a single, unvarying lens, they were given the opportunity to view the world from a fresh point of view, looking down at the world from the above. The point made is well taken and is critically important. Even small changes in a familiar situation can be large shifts in perspective and provide new ways that one may think of the world. Visiting the next door neighbor and looking back at one’s own abode provides an entirely different view and understanding of the house in relation to other houses than is typically enjoyed on a day to day basis. 

The reverse is also true. There is always the danger when standing atop the desk that this becomes the new status quo. That looking down upon the world becomes the new normal, the perceived reality. In extreme examples of this, such as the rockstar or movie star, one believes they are truly worth all of the hype, all of the adoring fans which they now enjoy. The top of the desk takes the place as the new status quo, and escaping the deadly grasp of the fame and applause can be all but impossible. The problem of the pedestal is not distinct from the problem of the pupil’s desk. Both are problems of restricted perspective and the acceptance that the current perception of reality from a fixed vantage point is objective truth. The problem is not a problem of the pedestal itself, but a problem of how static one’s place upon that pedestal becomes. The problem of pupil’s desk is not a problem of the pupil’s desk itself, but a problem of the inability to find another perspective. 

Multiple perspectives is the antidote to the problem of the pedestal. Triangulation, that is using multiple sources of information and data to locate an object or person, increases in accuracy with the number of sources of information that are utilized. Gaining multiple perspectives provides the same increase in accuracy. Seeing one’s position in the world, one’s place and role, one’s own striving and shortcomings from multiple perspectives more accurately paints a vivid picture of one’s true standing in relation to the world and others. At every stage in life, multiple perspectives should be sought out. Teaching and learning must occur simultaneously. If you often find yourself in a place where you are placed on a pedestal, seek experiences where you are unranked, unproven, the bottom of the totem pole. If you often find yourself at the bottom of the pecking order, always in the learner’s chair, find a place where you can practice leading and stick around long enough to train any newcomers. 

Seek out many perspective. Often change your view of the world and your place within. If you find yourself embracing the comfort and familiarity of your current perspective, the time has come to add a new perspective.

The best perspective is multiple perspectives.

The Happiest Place

Photo by Jayme McColgan

The happiest place on earth. That’s a lot of pressure. A place that you arrive to and are then forced to think, “this is the best that there is.” As you mill around in the line again it hits you, “It’s all downhill from here”. Later as you exit a creative ride with catchy music playing in the background, it dawns on you again, “I will never be as happy as this again.” After the fireworks show, the smell of Carmel corn in the air, you slowly meander out through the pleasantly lit streets. As you pass through the wrought iron gate, it hits you- everywhere is now a place of less happiness, of greater sadness and disappointment. “Is that it? Is that all?” You find yourself wondering. 

Vacations, recreation, and fun are, of course a great thing. They can snap the ordinary routine, invite us to think in new and exciting ways, and of course give us a respite from the daily grind. There are times when the festivities, the ceremony, and the hype is warranted and even helpful. Times when everyone wants to be carried on the notes coming from the stage, to drift along a glassy river, to pick things solely for pleasure and enjoyment, without any ulterior motive. Yet with happiness and satisfaction dictated as the delta between expectations and reality, promising to be the top, the ultimate experience appears dicey at best. 

Happiness makes a poor goal, a terrible target. Aim for happiness and you are sure to end up with empty hands. Perhaps the only way to actually guarantee unhappiness is to only pursue your own happiness and momentary pleasure every moment of every day. Aim for happiness and you will miss meaning and happiness. Yet if one selects meaning, that is endeavors to fill one’s time with things that elevate the status and standing of themselves and those around them, happiness, true happiness is the natural by-product. 

Perhaps the happiest place on earth is not the place where entertainment and sweet confections abound, but rather where good people work together on interesting problems. Perhaps one doesn’t need to travel long distances, purchase costly tickets, or wait in long lines to find an even happier place. Perhaps the happiest place can be a transformation of precisely where they are at this very moment. 

Make this place the happiest place on earth. 

Course Correction

Photo by Casey Horner @mischievous_penguins

One of the most dangerous decisions in life is unmonitored change. In medicine, making a change, whether it be a procedure, a medication, a lifestyle modification, or another form of therapy, requires follow-up. In many cases, this follow-up is equally, if not more important than the actual change. Follow-up may take a variety of forms. In some cases the follow-up is merely a symptoms check at a scheduled point in time. If the medication is for pain, depression, itching, swelling, gastrointestinal irregularity, or a whole host of other maladies, often the most important follow-up is whether those symptoms are improving, staying the same, or getting worse. In other cases, additional testing, whether checking blood pressure, specific blood levels, specialized laboratory tests, or repeat imaging may be the appropriate follow-up. While the change itself is, of course, important, the follow-up is essential. Is the new medication causing cramping? Is there new electrolyte abnormalities? Is there new side effects? The follow-up is critical because, while most changes do not result in immediate catastrophic events, continuing the current course without any plan to monitor and correct comes at the risk of an avoidable, significant adverse event in the future. In medicine this is why follow-up labs, imaging, appointments, and check-ins are vital. 

The same applies to life. Often the change itself is emphasized as the significant and important event. And of course this is true. Whether a new job, a new living situation, a new hobby, or a new relationship whether romantic or platonic, the follow-up is equally important. Starting a new job is a sentinel event, however once that new job is started it is uncommon to reevaluate whether they are accomplishing their larger life goals, whether their life is enhanced, and whether they could be doing something greater with their time. The same goes for a relationship, a house, or a hobby. Starting any of these things is exciting and important, however reevaluating at a specific point or points in the future is absolutely essential lest irreparable damage be done and irretrievable time be lost. 

The importance of the cycle of change and follow-up applies not only to macroscopic changes but also to the microscopic changes. Small changes within the job or the workday should be monitored to determine whether they enhance or detract from efficiency and productivity. Small changes in relationships should be reevaluated around the coffee table at specific, scheduled intervals. Changes to diet, exercise, morning routine, nighttime routine, even driving route, should be evaluated after these changes are made. Small course corrections prevent critical failures in navigation. A ship navigating the sea stays on course by routinely monitoring their position relative to fixed objects. Imaging a ship that navigated by making a change in course without plans to measure their position after a short interval to determine how that change had affected their overall trajectory. It would be highly unlikely that they would maintain their planned course and come anywhere close to their intended destination. Course corrections in life require follow-up lest small changes lead to large consequences. There is a constant, ongoing process of change and evaluation.

Follow-up is essential.

Good People, Interesting Problems

Photo by John Ko

Good people, interesting problems 

Most people do not have a singular driving passion, something that keeps them awake at night, something that wakes them up in the morning. They have many interests and enjoy doing multiple things. Their passion is not like an itch that relentless perturbs their consciousness reminding them that it is there. The majority of people do not have one passion that leaves them simultaneously breathless with excitement as well as nauseous with anxiety. Given the choice between their passion and Disneyland or a trip to an exotic island, most would be found a week later with mouse ears or a dark tan. And this is not a bad thing. 

So what do people without a singular driving passion do? How do they discover themselves or find meaning to their occupation. Are they doomed to years of mundane tasks and meaningless work? Of course not. Rather, this far more common path allows, in fact encourages, one to determine meaning and purpose as they go. Passion than follows. 

Good people and interesting problems are the two key components to finding meaning and pleasure in an occupation. A good group of people is absolutely essential. Hopefully the group is united by curiosity yet is largely heterogenous with people with different expertise, with different backgrounds, and with different ideas. While good people alone is enough to have a good time for a day or two, interesting problems are absolutely essential to long term meaning and purpose. Interesting questions unite the group and focus individuals on a common goal. 

There is a false, yet common belief that there is a dearth of good people to work with or interesting problems to be solved. Nothing could be farther from the truth. The problem is that many of the good people and the interesting problems that are the most visible are difficult to break into, and for good reason- they are already highly functional, developed, and productive. Yet there are near endless numbers of interesting problems and millions of good people that have yet to be tapped. Thankfully, many of these people do not have a singular driving passion and are thus able to unite around a common passion and goal. 

One final thought bears mentioning. Often the two of these are inextricably linked. Good people are attracted to interesting problems and interesting problems are often uncovered and refined by good people. If you have an incredible problem and a worthwhile solution, the good people will be naturally drawn in. Perhaps slowly at first, but they will come. Additionally if you find yourself amidst great and talented people that do not have a unifying passion, there are a plethora of unmet needs, common problems, and compelling obstacles to rally around. A good problem will present itself. 

Start with good people and an interesting problem. 

A Greater Game Is Afoot

Photo by Varun Yadav

A greater game is afoot.

Is there something beneath the surface that goes unseen yet underlies, even drives, everything that is seen above the surface? Does face value represent true value or is it a facade disguising something greater beneath? Does the image that our eyes perceive represent truth or is it merely an image masquerading as the truth. This is not to say that the superficial question, our surface impression is wrong or bad, simply that there is a greater reality, a greater game that is not readily apparent. 

Often families of patients who are critically ill will be, very reasonably, highly concerned about the condition of their loved one. Occasionally families or friends will fixate on specific values in the blood work or numbers in the chart. Fluctuations in electrolytes or blood markers become the focus of long conversations and debates. The superficial concern about potassium, sodium, creatinine, or blood cells overlies the far deeper concern regarding the overall state of the patient and their recovery. It is easy to answer the superficial question with a long discussion of electrolytes, buffers, cellular shifts, and repletion scales, yet this merely reinforces the focus on the superficial question without addressing the underlying concern. Addressing the overall condition and goals of the patient is far more reassuring and productive than a biochemistry lesson. Recognizing the greater game is essential to patient care. 

Game recognition is played out, either effectively or ineffectively, in relationships every day. Nearly all of the things that are points of contention and argument are not the points of conflict in and of themselves, but rather represent a greater underlying concerns. Being prompt is rarely about the technical aspects of showing up on time but rather communicating to the other party that their time is valued. Choosing the type of food is not about the food but rather valuing the desires of the other person. The five love languages, described by Gary Chapman, are simply distal manifestations communicating proximal commitment and love. Gifts are not about the object being transferred but are entirely about communicating that one party was thinking about and contemplating the likes and dislikes of the person whom they love. Quality time is not about the number of minutes and seconds but is entirely about intentionally selecting the other person over other activities and relationships. Words of affirmation are not about paying compliments but are entirely about valuing and recognizing the characteristics of the other individual. Physical touch is not about contact between epidermal surfaces but is about choosing to attend to the comfort and happiness of the other. Acts of service are not about the task being completed but about careful contemplation of the needs of the other person and the prioritization of those needs above personal needs. Without recognition of the greater game, love languages are simply dry exchanges, compulsory tasks without the robust and vibrant interplay between two individuals that is the point and goal, the greater game. Recognizing the greater game is essential to relationships. 

Game recognition is essential to allowing creativity and out of the box thinking. When a boss instructs you to shovel dirt from one pile to another to fill in a hole (something I have done at a couple points, usually when it was hot and dry, usually without a clear point), the point is not that the shovel must be used or that the dirt from above ground must be removed. Instead the point is that a hole must be filled in before the task can be considered complete. Recognition of this fact opens up many options for solving the problem instead of limiting possibilities to a single entity. This same concept plays out in radically more complex scenarios from running codes in the hospital to doing procedures to testing hypotheses and publishing papers. Without recognition of the greater game, taking initiative and complex problems solving is impossible. Recognizing the greater game is essential to productivity and creative thinking. 

Perhaps the most difficult thing about recognizing the greater game that is afoot is maintaining vigilance that there is always a greater game afoot. The default is superficial recognition because it is easier, requires less energy, and society is accepting of this status quo. This is one of the powerful benefits to practices like meditation and mindfulness. These practices force us to step outside of the immediate task and refocus on the greater picture. In a world with so much information available to anyone, anywhere, synthesis of relevant information into whole pictures, true games, is inestimably valuable.

The greatest game is to recognize that there is always a greater game afoot.