High Achiever Inertia.

(Rambling, idea sorting and unpacking ahead. Consider yourselves warned. )

"Keep on movin'. Don't stop like the hands of time."

~ Soul II Soul

____________________________________________________


I remember logging into the protected residency website that houses all of the call schedules a few years back. Waiting for the page to open has always felt like spinning a wheel on Wheel of Fortune--nearly every possible wedge upon which the wheel can land is mostly good with only the very rare BANKRUPT tab. That said, even rarer is the $5000 mark that happens about as frequently as a lunar eclipse. The resident and intern assignment odds are fortunately better than game show ones. The chances of hitting it big are much greater and, even better, the BANKRUPT tab is nearly nonexistent.

(reference photo for folks to young to get the reference.)

Yup.

So this particular month, Vanna White was on my side. I scanned the list and did the slow Tiger Woods fist pump.

No, seriously. Almost exactly like this:

Yes. I'd hit it BIG on the scheduling game show this time. Matter of fact, this was right up there with somebody yelling out, "A NEW CAR!"

Oh yeah, baby.

Interns: solid. Medical students: Not familiar with them but likely solid, too. But the Tiger Woods celebratory gesture? Oh that was for the person designated to lighten my load--the resident assigned as my right hand woman. The scheduling gods blessed me with a RISING CHIEF RESIDENT. Did you get that? Let me explain. See, this senior resident assigned to me had already been asked to be a chief resident--which in a land of smart people is a big deal. So suffice it to say, she was as smart as five whips cracking all at the same time on the same behind. Now that? That's smart, baby.

Mmm hmmm.

So yeah. I did the happy dance and bragged to a few of my colleagues when queried about my resident for the coming month. It was the summer time and let me tell you--the living was about to be easy. For me, at least.

Now. Sure, I went through those fleeting thoughts of terror with regard to working with someone so smart and highly competent. And yeah, I shuddered a few times imagining some clinical curve ball being hit directly to me and, instead of knocking it out of the park, completely striking out. . . only to have the uber-genius future chief resident come right behind me and smash a grand slam into the rafters. Off of the same pitch.

Yeah. I thought those things but honestly, this resident was not only smart and a future chief resident--she was someone that I knew fairly well already. We'd had a good working relationship from the clinic so I knew that this would be a piece of cake.

Oh yeah, baby.

Now. Let me just discuss for a bit on just WHY I was so happy about this assignment. The truth is that it wasn't just about the fact that she was bright and pleasant and considered one of our best. If I am honest--and I try hard to be on this blog--it was more an opportunity to put my brain on ice for a little while. No--not from the patient care standpoint so much. More from the stressors of looking over my shoulder and under every little nook and cranny for something wrong.

And.

No sort of remediation would be needed. What. So. Ever. Hallelujah, man.

And so. I was going to show up with a plan to simply let this superstar resident do her thing. Because the word was not only out on her level of competence--I'd seen it first hand. Moreover, she was in her final year of residency so what was the point of me coming up with some sort of hair brained scheme to transform her in any kind of way?

And this? This is what I am reflecting on today. This thing that I have discovered that happens with a lot of high performing individuals after a while. This point where, instead of us pushing hard and finding ways to help them excel in new ways, we simply shut off all of our faculties and put it all into cruise control. And you know what? Even though it doesn't feel that way, it's like giving up.

Yeah. I said it. Giving up.

It's so pervasive, too. Even though it doesn't create a mutiny and even though for the most part the learners themselves don't even know it's happening--it is. A lot. Even with the really, really great educators it is.

It is.

Sure, at the beginning we push them and applaud their every milestone but there is this threshold that gets crossed where, as I mentioned before, the word is out. He or she is uber-exceptional and has already been given some sort of metaphorical gold star to prove it. So what do we do? We throw our hands behind our heads, lean back in our chairs, and snooze for a little while.

And okay, okay. If you don't like me saying "we" I will just go ahead and raise my own hand and say "me." Because not only have I been guilty of it, now that I am thinking about it and dissecting this idea, I recognize it as something that happened to me at several different points in my training and beyond.

Let me explain.

Usually it starts with some person planting a seed about just WHO this person you're working with is and just how awesome-great-amazing-the best-superstarish-thebombdotcom that they are. And sometimes you've seen it for yourself but a lot of times, you haven't. You just roll with it. Then the person shows up and what you see is through that lens. Which is mostly fine. And often accurate.

But.

What happens next is the thing that since that month with Tiffany (the rising chief resident assigned to me that year) that I've been trying to fight. It's a sort of inertia. I like to call it "high achiever inertia." This point where everyone sort of gives up on trying to do anything special to bring out an even better version of the person who everyone is telling you is already the best.

Did that even make sense? Stay with me. I'm going somewhere,

So check it. Usually there are heaps and heaps of flattery involved. From the start whether warranted or not, the person is lauded as fantastic and a star before they've even done one thing. As time marches on, the sweet words prove to be as empty as sweet foods--delicious to hear but of no real nutritional value. Feedback sessions morph into these nondescript proclamations of excellence without examples. And the person on the receiving in--who is human--eats it all up without even realizing that it was not a balanced meal at all. Or worse--that for the last several months, they've been fed the same, exact plate of food.

Yup.

I know how this feels. I lived through the "hey, you're going to be chief resident!" announcement and experienced the stealthy downshift in meaningful nudging toward new potentials that came from those who worked with me. And I didn't even know it was happening for the most part. I didn't.

Then, during my chief year, my Internal Medicine chairman, Dr. Blinkhorn, started having these weekly meetings with me. He'd give me specific feedback on my teaching and would ask me provocative questions about how I was running my ward teams. He wanted to know about the feedback I gave to learners, what I did at the bedside, and more. The points I made on the chalkboard--though often salient--he challenged. Questions like, "Who are your learners?" and "Do you think that was as effective as it could have been?" were common. He'd even say to me, "You look exhilarated. I can tell that session felt good and like you were in the zone up there today. Let's talk about why."

And that? That was awesome. Just freaking awesome.

Two or three days into working with Tiffany, things were going fine. It was as I had anticipated: She was exceptional in a myriad of ways and I was enjoying the welcomed diastole that came with along with it. But then something happened with a patient. Nothing wrong at all. Just a situation where I watched this excellent resident physician navigate one aspect of patient care into which my personal experience afforded me insight. And so. I took a moment to chat with her about it.

Yep.

Something about that conversation triggered an onslaught of memories. Specifically, I was transported back to those Tuesdays with Blinkhorn and just how pivotal they'd been for me. I put that on a post-it note in my head and vowed to come back to it later that day.

And I did.

That lead to a gigantic ah hah moment. Dr. Blinkhorn did something that very few people had done for me. He fought against the downhill momentum of "high achiever inertia." This was more than someone choosing to push a learner from good to great. This was something that was, in my opinion, even more profound. He approached his chief residents--the ones he'd personally selected--as if he could move them from what many perceived as great to even greater. And instilled in me this idea that we are never ever there. The destination is always moving higher and higher, forcing us all into a zone of development that we deserve.

Yes. That. This zone of development--not some high achiever comfort zone where everything morphs into the predictable and straightforward and hence the default of flattery takes the place of real, true strategy.  That.

So that got my wheels turning. And so. I asked myself:

What if. . . like. . . what if I actually set out to do something transformative with this learner? This one. This known-to-be-already-excellent learner? What if, in spite of everyone saying "oh me, oh my, your resident is awesome". . . what if I actually had the audacity to think that I could still do something to push her deeper into the zone of development? What if? What would that even look like? What would that even feel like? And. . . what would that take? What would that mean to a learner like Tiffany who, by everyone's standards, is at the top of the pack for her current level? Hell, what would it mean to me?

Well. I'll tell you. It would mean planning on my part. It would involve thinking and preparing in ways that I hadn't before. It would call for a boldness and a confidence that I'd not yet fully challenged myself with and a trust in my own ability to actually do something meaningful with someone like her. That was uncharted territory for me. So was I insecure about it? You bet I was.

Let me tell you what happened. It was transformative indeed. But not just for Tiffany. It pushed me into a zone of development and called for something more from me. I tapped into creativity and honesty that had previously lay dormant in such situations and the outcome? Man. It was awesome. 

Yeah.

So I guess that's what I've been thinking about. How to not give up on the high achievers or the proficient performers. And you know? This isn't just in the work place, either. This can be applied in other aspects of life, too. Kind of like the way your child who calls for more academic or personal attention from you somehow seems to get all of it, while (hallelujah) the other one just plugs away independently. In between moments with the needier one, you do what just might be the minimum--checking always finished and correct homework, giving high fives, and feeling grateful as all get out. Which is fine sometimes but when sustained is really no different that that same idea of coasting along in the cruise control of high achiever inertia.

Or in this case, easy kid inertia. 

Whoops. My bad. If your toes hurt from that last part, just know that the person who stepped on them has just had hers crushed as well.

Ummm yeah.


But I digress. So let me get back to a professional context before some toes get amputated.

I guess the thing is. . . . .these guys will usually be fine, you know? These high achievers--they will. And some piece of you knows it which is why we don't fully freak out  about or even think about this--as the giver-upper or the giver-uppee. But imagine--just imagine--what it would be like if they, too, got the level of thought and preparation as everyone? Or better yet, more than just back slaps and applause to fuel their independent development?

I think those greats would be even greater. And, even better, they'd pay it forward first chance they got.  You'd better believe they would. At some point, at least.

When Tiffany finished her chief residency, during her parting words she said one of the kindest, most memorable and most encouraging things I've ever heard any learner or colleague say about me to date. And, at the risk of sounding self important, I will share it--not because I need to puff out my chest--but more because what she said serves as a tangible affirmation of something I was really trying to do. As lofty as it sounds, I was trying to be transformative. I should also note that Tiffany was known for being stoic which made her words just that much more meaningful.

She said:

"No attending had more influence on me during my training than her. Doing a month on wards with Kim Manning as your attending should be a required part of our curriculum for all residents."

Yes. That is what this high achiever who'd already been asked to be chief resident, who'd arrived on my team as "one of those residents that everyone knows is awesome," and who just maybe knew more medical facts than me said in my earshot to a roomful of people.

Uhhh, yeah.

This simple statement will always be high on the list of the proudest moments of my career to date. Because I knew how hard I'd tried. And you know what else? It moved me so greatly that I quickly typed it nearly verbatim into my the my phone for posterity.

Okay maybe posterity is a strong word. But I at least wanted to have those words to revisit and unpack for later.

Sigh.

Here's the thing: No award was given with it. And nope, no plaque, publication, or confetti either. But that? What she said that day? Man. That's what I hear in my head on my shittiest days. It's what pumps me up when I feel myself giving up or falling into a lazy pattern that isn't unique to THAT learner.

Is it exhausting? Hell yes. But the reward is insurmountable. And freaking awesome.

Look. I can't say that every strong learner that I've encountered before Tiffany W. got some watered down, lazy educational experience from me. But I think the difference is that the level of intention I have when working with those performing at that level changed. And thanks to her, I actually believed I could make a difference. Even with the less junior trainees, I started to believe I could.

Yep.

So that's what happened. And that's what I challenge myself to do every single chance I get. For the known superstars, yes. But also for the ones who are superstars in disguise.

Which reminds me: I wish I had time to talk to y'all about how a lot of superstars get mistaken for average.

Mmmm hmmmm.

But that's another subject from another post. Oh. It's in this one, actually.

Ha.

Okay. This has been long enough so let me just wrap it up with this final thought:

If you keep trying at this and being intentional about what you do with every single learner, after a while perhaps a different word will get out. Yeah, man. Not that you're just nice or competent or full of random facts.  Maybe an expectation will get handed around that this person--you--just might be bold enough to try to transform those working with you. Even if they're not a problem child or someone super junior or someone who's been dubbed "just okay." Yes. Even if that person is known to be a star, the rumor might be that you'll still try to make them shine even brighter or in ways they hadn't before. So then no one will show up expecting an experience with you to be super-comfy and vanilla.

Nope.

They'll arrive with a nervous disposition expecting to be a little uncomfortable. Not too uncomfortable. Just kind of. I mean, maybe this could happen, you know? This could be the new word on the street when it comes to you. Even amongst the superstars.

with Tiffany at her Chief Resident farewell program

Then guess what? YOU'LL get forced into a zone of development right along with them. . . . . .the same one that we're all hungry to inhabit but that we don't realize we craved until we're there.

Yeah.

Jen S. and Lucas G. -- two that challenge me constantly. And I love it.

****

Okay. Here's the challenge for everyone reading this who works with someone excellent: Don't give up on them. Don't just float on your back in the pool basking in the sunshine without moving. Because when that happens on your watch, they stagnate. And when they stagnate you do, too. But guess what? When you push them into the zone of development, you go there, too.

Every. Single. Time.

*Based on Vygotsky's Zone of Proximal development--a concept that I like.

***
Happy Sunday.

Whew. That was a lot. I know. And maybe it made zero sense to you. And maybe it set off alarms for you instead. But either way, I appreciate you letting me unpack, okay? I really do. Keep on moving, y'all.

Now playing on my mental iPod. . . . a song that blasted in my dorm room many a day and many a night circa 1990. Soul II Soul singing "Keep on movin'."

What it's like.

It's like saying your Easter speech and getting a standing ovation from the whole congregation--even when you didn't get all of the lines right.

It's like coming home from college with your University sweatshirt on and noticing a glisten in the eyes of the proud elders when they see you.

It's like the first day of school and the last day of school--but at the same time.

It's like riding your bike without training wheels for the first time down the big hill.

It's like the gigantic Christmas Day crossword puzzle in the New York Times or the Atlanta Journal Constitution that seems impossible to solve. But that you stay at all day and all night because some piece of you believes that it can be. And should be.

It's like that feeling that wells up in your chest when you hear someone hit the biggest notes in a gospel song.

It's like coming home from summer vacation and learning that your very best friend on your block has moved away for good.

It's like dancing in rain; you get soaked but it feels good and right.

It's like loud music booming from the speakers of a souped up muscle car but also like the symphony, too.

It's like running to the top of those stairs like Rocky did and finally reaching the top out of breath.

It's like locking your keys in the car and not having any idea how you'll get them out.

It's like being given the key to a diary every day and being trusted to read it, carefully lock it back, and keep the contents hush.

It's like watching someone throw dirt on top of a casket of someone you love.

It's like going back in the bathroom to check a pregnancy test and finding out it is positive.

It's like going back in the bathroom to check a pregnancy test and finding out it is negative.

It's like sitting next to your daddy in his Lincoln Continental as he plays Donny Hathaway singing "Young, Gifted and Black" for you on the tape deck. And not moving because he admonished you to soak up every word.

It's like re-listening to Dinah Washington singing "This Bitter Earth" as an adult--another from your daddy's collection--and this time actually having something to relate it to.

It's like the sting of a bad, bad breakup.

It's like the euphoria of brand, new love.

It's like the hug your mama gives you after you've fallen and skinned your knee.

It's like the hug your sister gives you after that bad, bad breakup.

It's like the angst of waiting for the school bell to ring when you know a fight awaits you on the playground.

It's like the long walk home with a bad report card.

It's like finding out you're going to DisneyWorld.

It's like the rap song you know all the words to coming on the radio--and not caring that people laugh at you while you recite each word.

It's like missing your plane right after the doors close.

It's like making your plane right before the doors close.

It's like morning yoga on a crisp autumn day in the mountains.

It's like coming home and seeing flowers waiting for you on your doorsteps.

It's like the sun; sometimes too hot, but usually welcomed.

It's like feeling the hand of God sometimes. Even if you're someone who isn't so sure what that means.

Someone asked me what it's like to be a Grady doctor. And at that time I was at a loss for words. But now? I'm not.

Honestly? It's like all of these things, which are really just the rhythm of life . . . . with its ticking metronome of high-highs and low-lows. Yes, that. 

I doubt that the person who asked me will ever read this. But I will. I will read it again and again and again.

Yeah.

***
Happy Tuesday. Again.

Now playing on my mental iPod. . . . first Donny Hathaway singing the song my daddy played for me in middle school that I can't wait to play for my own children. So life affirming.



Next, this. . . .Miss Dinah Washington singing about pieces of the what I see each day. . . .




.  .and last. . .gospel singer Yolanda Adams hitting the big notes and taking the wind from my chest. Just like so many of my days at Grady.

To care, perchance to love.

I met a man in the hospital the other day and fell in love with him. Well. Not "in love" in the eros sense with, like, flying cupids and romantic butterflies. But love nonetheless. It was immediate, too. Kind of like the way people describe meeting someone and falling in love at first sight.

With him, it wasn't so much me laying eyes on him that made me fall in love. It was his throaty laugh and gentlemanly mannerisms. It was in the conversation I heard him having on the phone with his daughter, massaging down her worry the best he could with brave jokes and soft chuckles. I could tell that allaying his family's fears was more important than tackling his own.

I loved the way he said "Miss Kimberly" before every question and how, no matter what I said, he would nod and thank me. He knew that I was a doctor. Somewhere in our interactions, though, perhaps that felt too formal. Maybe not. But whatever the reason, not only did I not mind him calling me "Miss Kimberly," I actually welcomed it. I did.

His admission was for the thing you don't want people to come in reporting--unexplained weight loss and loss of appetite. Vague abdominal pain and "maybe some kind of knot" in his abdomen. It was bad from the start. Sunken in temples and skin outlining high cheekbones that jutted out prominently since they didn't have to compete with subcutaneous fat. All it took was one look and I knew. This was bad.

But even worse was the story behind the diagnosis. One of those things that, had he been in a doctor's care, quite possibly could have and would have been caught. Or maybe even prevented altogether. Maybe. Like really and truly maybe.

So loving him made this harder. We made the diagnosis and called the necessary parties in to talk about the treatment. At this point, there wasn't a whole, whole lot in the way of "treatment" although there would be palliative things to offer. And he was stoic, that man. Tough as nails and with the courage of ten lions. He looked me in my eye and said, "Okay. I'm okay and I will handle this fine." And he wasn't saying it because that was what you're supposed to say either. He said it because his insight was excellent and he'd been around living his life as a patriarch long enough to know that sometimes you just have to take what's been handed to you and, well, handle it. Which was what, I think, he'd made up his mind to do.

But I loved him. Really, I did. Even though I took care of him for less than three and a half days, I loved him. Loved him enough to be mad that it was too late for anything short of a miracle and madder that I hadn't met him sooner.

In front of my team I was regular sad. Like, "Man, I hate this" sad but not really much more. But in the safety of a conversation with my very dear friend and Grady doctor, Lesley M., I grieved.  And no, I'm not being dramatic by saying "grieved" either. I wept into the phone and told her how very, very sad I was about this man that I now loved and how badly I wished she or I had met him ten years ago. Met him and ran his labs and said, "You know? Let me check this" and then discovered all of this earlier. But I've been living and doing this long enough to know that a lot of times the reciprocating circuit of "if I coulda woulda shoulda" is as futile as a dog chasing his tail.

But still. I loved him. And today I'm sad because this is going to silence his beautiful, smokey laugh and quiet his glistening eyes. Short of a miracle, it will.

I allow myself love patients--and people--in this way. I do. It leaves me raw and vulnerable, yes, but still. I would much rather feel it than not care. If meeting that man and telling him such bad news ever became "business as usual" for me, that would make me far more sad. Far, far more sad.

My friend Shanta always speaks of the privilege of stepping into human lives and caring for them as their physician. I hear her voice and savor that idea. It is indeed a privilege and an honor. To care, perchance to love. Even if sometimes, it hurts when we do.

Yeah.

***
Happy Saturday. Gotta go round now.

Time to Teach.

I don't want to be a human speed breaker--
some wretched intrusion to your hasty departure
from the hospital

I hate imagining that my bright eyes create too much of a glare for you
or that my bushy tail gets in the way of what you have to do
I don't want to think things like that

but sometimes that's how it feels

It isn't my preference to be scuttled off into dusty corners
pseudo-encouraged to explore answers to sidebar questions
that you may or may not even care about

or at least care to hear about from me

It doesn't elate me to be dismissed with the sun still high in the sky
nudged out of the building
but mostly out of your way while you tend to the things
that I long to learn all about

"I wish there was more time to teach," you told me
because if there were you'd show me all kinds of things
and explain more of the nitty gritty of what you're doing

You would but you can't
because there's too much to do and not enough time

Never enough time
especially to teach me in the ways you want to teach me

And so
I sit in the shadows while you scroll through screens
your industrious gaze mostly indifferent broken occasionally by an obligatory smile
then I walk behind you asking the questions 
the ones that I hope might unlock the door and invite me in
into the reasoning, the bedside discoveries, and the sticky conundrums
into the subtle interactions that can and will shape me into a real doctor

But today, you don't because there just isn't enough time
you blanket me with compliments
before sending me in the opposite direction

away from you
away from them
away from the parts I signed up for and always dream of

And yes
I know you wish there was more time to teach me--
the human speed breaker standing between you and "done for the day"--
and yes, I know that you wish you knew what to do with me

But 

You know what I wish?
I wish you knew the truth

that there's always time to teach
and that you're always teaching me

whether you intend to or not

***
Happy Wednesday.

Oh yeah!

Tonight is our 3rd Annual Fellows Teaching Competition at Emory. The Department of Medicine sponsors this amazing event celebrating our dynamic junior teachers--those in fellowship training. Each has prepared an 8 minute lecture that they'll present to a full house and a panel of esteemed judges. The one with the top score takes home a substantial cash prize. Why? Because we want to put our money where our mouth is when it comes to letting our learners and institution know that we value medical education. Every year this event excites us all and reaffirms what those busy days make us forget--that there's always time to teach.

The order of the speakers tonight was selected by the unbiased and sticky fingers of the seven year-old boy pictured below. Oh, and you can read this post to learn more about the Fellows Teaching Competition.

Had to add this. . . .

When you take the time to teach, learners be like. . . .