Friday, June 24, 2022

A Perpetual Gift of Happiness and Peace

A teaching by Gen-la Kelsang Dekyong at the Kadampa Meditation Center Phoenix on virtuous mindsets had a profound impact on me. Many of us think that if we work hard, then we'll earn a lot of money and we'll be happy; or if we find our soul mate, then we'll be happy; or if we get our dream job (dream home, dream body etc), then we'll be happy. The reverse can be true also. If we never have to seen this [individual, job, object...], then we'll be happy. What happens when these wish(es) come true? We find ourselves not has happy as we thought we'd be. The big house didn't make us happy; neither did the dream job, nor the dream partner.  However, we can adopt mindsets that are perpetually giving and the more we cultivate these mindsets, the the happier we become. We can practice these mindsets now, everyday, and all the time. One of these mindsets is compassion. Compassion is to understand another being and then act in a positive way to improve their well-being. How do we do this? A simple compassionate act we do is to wish them well. I've come to learn that this simple mindset (to wish someone well) has been so effective in improving both the relationships I care about, and more importantly, this mindset has helped with relationships that create discomfort for me. Sometimes, we don’t jive with for whatever reasons with someone, and you might avoid interacting with them because of the awkward nature of those moments. For example, I work with a colleague at work. We are cordial to each other but there is some tension that exists because of a shared project that didn't quite go as expected.It’s  easy for me to get upset, disappointed, or rationalize in my head why the ball got dropped, and point the fingers. However, none of these thoughts help me, the other person or the project. Now, instead, I say in my head "may s/he be happy, may the project success to achieving its goals, and may we move forward together, and with ease". After I say that compassionate statement to myself, all of the sudden, the tension ease, the frustration softens, and mind clears.  If someone cuts you off in the freeway, then instead of cursing or flipping out,  you can cultivate compassionate thought "may s/he be safe, be happy; may the desire that led them to cut me off turn out to be okay for them." You can do this all day long and with all interactions, good or bad, neutral or borderline. When you find yourself passing a judgement/ harboring  a negative thought/ boiling up with  anger, then you can replace that with a compassionate mindset.  This approach helps you, helps others, and gives peace and happiness every single time, with every act, every word, every thought, and every actions.  Over time, the cumulative effect on this simple habit can transform us and bring inner peace and joy that unparalleled to none. All involved share in on the benefits. Now, when I find myself tense thinking about someone, or witness an unpleasant action or hear dismissive words, then I pause, and wish them well. 

Cultivating these positive mindsets is critical because I think people can sense and know how we feel about them without having to say a word. Our thoughts somehow sends an invisible but very palpable vibe to those around us, even when we are not directly interacting with each other. The mindset that we adopt often gets translated in our body language, tone, and our demeanor.  Sometimes, when I'm passing a judgement, I often feel like the other person can read my mind and I get nervous  even though I've said nothing. Now, when I adopt the compassionate mindset, then my body, expression and demeanor relaxes, and I bet the same invisible but positive vibe is felt by the individual.  This approach has completely transformed my day to day interactions especially with the challenging ones. When I interact with a trainee at work that I used to feel equivocal about, instead of adopting a semi-avoidant behavior, I say to my "may I be the best teacher possible, so that this individual may learn, and be effective, etc". My mind and feeling shift immediately, and I feel comfortable around the trainee, and inevitably, the interaction turns positive and productive. When I don't get a request that I've submitted at work, then I say to myself "may this person have the resources s/he needs to be an incredible leader, and to support all those s/he leads.". I even do this with strangers, like our cleaning crew.  I try to wish them well and send them compassionate and positive thoughts and vibes as I pass them by. The power of compassion is endless. With each cultivation of compassionate thought, the happier and more peaceful we become. Try it out. Replace your negative reactions with positive compassionate thoughts; replace your judgements with well-wishing; replace your neutral position with active well meaning  thoughts; share and spread your compassionate vibes to people you know and don't know, and do it with every interaction, and everyday. You'll transform yourself and will increase your peace and joy immediately, with cumulative effects that magnify over time. 

Thursday, June 23, 2022

Reframing Life as a Suitcase to prioritize what matters

 Burnout, over commitment, and stress are epidemic, especially among working professionals. Too often we are told to prioritize, focus and say no to anything and all things we do not care for. This approach can be challenging, especially for junior and inexperienced folks. It's easier to agree and then suffer from the over commitment later on. We take our time and our bandwidth for granted; we overestimate how much time and headspace we have and over inflate our abilities. We expect a lot from ourselves, and all of this comes at a cost (lack of free time, underdeveloped relationships, estranged family, etc). When we become stressed, we try to increase the efficiency. We'll cut out our lunch breaks, multi-task, work longer hours, work harder etc. 

I read an article on efficiency, and the article compared Life to a suitcase. We can roll up our clothes, and squeeze in every nook and cranny of the suitcase, but efficiency can only go so far. The space is fixed, and at some point, you'll have to sort the things you want to take, and leave the rest behind. Frequent travelers are pro at packing. They know what the bare essentials and unforgivingly leave behind all things that do not serve a purpose. In the same way, if we reframe life as a suitcase with limited time, and the prospect of travel as experiences in our life, then perhaps we will have a better sense of what to take with us and what to leave behind. What are your bare essentials? If one suitcase equated to 1 year of life, then we only have 80 suitcases to fill, which is not much. Life is short. When I imagine my day, week, month, year in terms of life suitcases, I find it much easier to see clearly what is important, what's borderline, and what definitely is not worthwhile. For example, one consideration I've entertained for sometime is the idea of decreasing my work full time status. If/when I cut back on work (which is easy to say and hard to do), then we can free up time and give ourselves space. But, it comes at the cost of decreased income and the associated cringe that comes with that idea. If instead, I imagine my life suitcase full of money and no free time vs less money but more free time, then the right answer is more obvious to me. Time is a non-renewable, fixed and invaluable resource. The image of packing my life full of work and no time to play sounds unpleasant; instead a suitcase containing just enough while also making space and time to explore, learn, travel, develop relationships seem so amazing. Next time you're stuck and unsure how to move forward, ask you self  what would you take with you in your Life suitcase today, this week, this month? Anything you take means less space for something else. What would an amazing day, an amazing week, an amazing year look like?  Then, pack your life full of all the goodies, and let go of the rest.

Thursday, March 24, 2022

Back to Work (In-Person): Reflections

One of my goals is to live and be in the place of abundance...of time, energy, creativity, space, love, compassion, mindfulness. 

In the last two months of working hybrid model, I was fortunate to be able to work in a hybrid model (half on site, and half remote). We've been back on-site fully for a couple of weeks after COVID subsided. 

I've made an interesting observation about myself since transitioning back to traditional on-site model. With hybrid work, I felt like I had more energy after work compared to fully on-site work. I'm attributing (and I could be wrong) the difference in energy levels due to the work space and environment. 

With remote work at home, my workstation is in a room with two large windows with plantation blinds that allow the beautiful, spring warm sunlight to cast its rays in my workspace. The window looks out into my backyard, which is borders Arizona Open Nature Space, full of wild Arizonian flora and wildlife. The room has direct door access to the backyard, and I keep the door slightly ajar throughout the day to allow the wonderful Arizonian desert air with aromatic pollens from the flowering plants to flow into the the room, and chips from the birds resonate into the room. The walls in the room are decorated with photos of my family and friends, and a large canvas of Arizonian succulents. I felt great and after work, I had the vigor and motivation which often led me to go for a run or hike on the trails leading to the nearby mountains. 

With on-site work, well, it's a radiology reading room. The room is dimly lit, and it's in a clean, nature and sunlight-free standard office with dark blue/grey walls. That's it. 

In the book Joyful by Ingrid Fetell Lee, the author discusses the power of ordinary things that create extraordinary happiness. In her book, she discusses the importance of nature and sunlight contributing to our happiness, peace and joy.  She says nature provides a form of mental abundance due to the open space and variations in sensory stimulations we experience. In contrast, being in closed quarters with stagnant air and lack of surrounding nature (artificial or real) make us feel confined and can sap the joy and vigor in our lives. When I spoke to my mother about this phenomena, she drew an analogy to plants. She said humans are like plants, we need nature touches (sun, wind, smell, etc) to thrive.  Otherwise, we slowly wither like a plant deprived of these necessary elements. The effects are more pronounced in children. The effects of nature exposure to children improved cognitive function (increased concentration, greater attention, higher academic performance), better motor coordination, reduced stress, increase social interaction (Strife et al).  Shankar Vedantam deeps dive in to the the idea of how nature improves our lives in his NPR Hidden Brain podcast "Our Better Nature: How The Great Outdoors Can Improve Your Life" In Chicago replica housing projects, high-capacity high rises with green spaces led to 15-20% drop in incidences of violence and police calls compared to housing projects without nature spaces. Artificial sounds of birds projected from audio system embedded in landscapes in high-violent neighborhoods led to a drop of violence by nearly 10%. Breathing air in the nature led to increase in NK cells, which contributed to healthier immune systems compared to air from urban spaces. Research from Well Living Lab, a Delos and Mayo Clinic collaboration, shows that offices with windows improve workers' productivity,  and satisfaction. Centers have coined the term "biophilia". "Bio, life. Philia, meaning love. So we have a love for nature," says Dr. Bauer. Areas with windows which provide natural light and views of the outdoors improve cognitive performance and increase well being. Exposure to nature led to calming effects. Contemporary cultures such as Japan advocate for Forest Bathing to offer an antidote to burnout.  Large tech companies like Facebook are designing work spaces that integrate nature, sunlight and green spaces to improve the well-being of their employees and staff. 

I think the workspace made a significant contribution to the difference in experience. I think days when I have more access to sunlight, view of natural spaces, and other natural sensory stimulations, I feel good all the day long. After I finished work, I felt light, and energetic, and often went for a walk/hike, and in the evenings, I was fully present with my daughter in the evenings. I logged in many more steps. I felt Virya, the Buddhist term for energy and enthusiasm that led one to pursue wholesome activities. In addition, I was in a state of abundance.  When I work in dimly lit, nature-free spaces like the reading room for 10 hours a day, I feel less good after work...and in fact, not infrequently, irritable / stressed.  

Obviously, different people will have different experiences from hybrid working. Some people appreciate the commute-free day, and others benefit from the flexibility.  A good friend told me she went to a yoga class in the middle of the day after she caught on her work. She felt so amazing from the yoga class and came back to the work list feeling great. The yoga time completely transformed her experience. She ended a busy work shift a little healthier, flexible and a lot more happier. Arun Krishnaraj from University of Virginia delivered the New Horizon lecture at 2022 Society of Abdominal Radiology meeting in early March and shared with the audience the need to provide our workforce a hybrid work option, and its importance to promote a healthy and sustainable workforce. Early adopters including New York University, and Cleveland Clinic have offered remote working options due to recruitment needs, and a few of my academic powerhouse friends have moved to these 100% fully remote working models, which have dramatically improved their quality of lives.  There are also negative sides to hybrid working (limited social interactions, potentially suboptimal educational experiences for learners, etc). However, I think the benefits could potentially outweigh the risks if the schedules are designed thoughtfully and iterated to preserve important interactions. 

Having had a taste of how amazing hybrid work option is, I'm super excited about how radiology will be unfolding over the short and intermediate term. I am going to unabashedly put a plug for the RadioGraphics invited commentary I co-authored with a good friend pre-COVID, in 2018 about this topic ( When we provide work options, we provide people with an opportunity to live and work in a place and be in the place of abundance. 

Sekhar A, Tan N. Invited Commentary on "Navigating Generational Differences in Radiology". Radiographics. 2018 Oct;38(6):1679-1681. doi: 10.1148/rg.2018180197. PMID: 30303787.

Saturday, February 5, 2022

Mental Immunity

I read The Book of Joy by Dalai Lama and Desmond Tutu and I am currently reading Daniel Kahneman Thinking, Fast and Slow. A common theme emerged among the two books that impacted my own views and perspective. Specifically, I've come to develop my higher levels of control through practicing mindfulness through meditation, which then allows me to regulate my emotional range and mental well-being.

More so in the past, and especially during residency, fellowship and early years of clinical practice, the successes and failures impacted me significantly. When I decided to switch from urology residency to radiology residency, I had major doubts about myself, confidence, and competence which created a fiery amount of stress and pressure to work harder, be better, and to "succeed". When I got rejected by the first several grants, I got down and discouraged. Eventually, I came to secure successes with clinical excellence, papers, grants and awards. With each success, I got elated, excited and encouraged. The ebb and flow of career (and perhaps personal) life feels like riding the hamster wheel. It felt like a trap, a dungeon of sorts, being influenced by the successes and failures of my efforts, and being like a boat in the open waters, controlled by the tides.

Over the past year, I came to learn a Buddhist teaching about the value of staying calm and still. Instead of letting mental well-being depend on the pendulum swings of various challenges we face and successes we achieve, we practice control of our natural emotions. By doing so, we can graciously accept both our success and failures equally, recognize the merit in both with the same amount of respect and thought. We no longer suffer disappointment with failure nor do we live with the highs of our success. Instead, we treat both as equal, stay unperturbed and adjust our course as needed.

In the Book of Joy, the Dalai Lama describes "Mental Immunity" which is controlled by our higher level thinking. In Kahneman's idea of fast and slow thinking, he defined systems 1 and 2, and the latter (system 2) can support the Dalai Lama’s idea of mental immunity. System 1 is our automatic, subconscious, intuitive mental state, controlled by our limbic system brain…our “fight or flight” system. Some refer to system 1 as the “lizard brain” and reacts unconsciously to things like threat and other intense emotional states. For example, if you see the tiger, your system 1 will kick in automatically and you’ll react. System 1 is flawed and has many pitfalls in our lives. For example, if you get a nasty email with degrading words from a colleague, system 1 will kick in and we may respond in ways that we may regret later if we don’t override our natural tendencies. In contrast, System 2 makes up our higher level, conscious thought, and is regulated by the prefrontal cortex. In the email example, we may decide to wait 1 day to let the emotions subside so that we can let system 2 think through the best way to respond and ensure we preserve good relationships. Perhaps, we decide to meet the individual in person or talk over the phone instead of an email response to resolve the concerns. The emotional center, our amygdala, is like the traffic control and supports our emotional reactions or responses to events and signals.  We can strengthen the signals and tracks that connect our amygdala to prefrontal cortex (higher level thinking) and limbic system (fight or flight thinking). 
The Dalai Lama draws an analogy of physical well-being to mental well-being, and coined the term “mental immunity”. We develop good habits (eating well, exercising, sleeping, etc) to be physically healthy, to boost our physical immunity to fight off colds, sickness and feel good. In the same way, he urges us to develop mental immunity, practicing our mental state to develop and focus on attention and concentration through meditation, so that we can develop mental immunity to struggles we will encounter. The mental immunity refers to system 2, our higher level control center of mindfulness. Activation of system 2 requires focused attention, concentration which ultimately yield mindfulness and awareness. Mindfulness is defined by two components: attention and concentration. When we have mindfulness, we can pause, reign in our intuitive and natural tendencies, and redirect our attention and concentration to the productive path, free of emotional swings. Practicing mindfulness through meditation allows us to strengthen our ability to access and control system 2.

We have different intrinsic ability to control our mental state, system 2, and more importantly we can develop this ability through practice. The famous Stanford Marshmallow test of a bunch of 5 year old kids illustrated our intrinsic ability to control our behavior. Each kid was put into an empty, boring, white, and bland room with a marshmallow on a plate, placed on the table. The rest of the room remains void of toys, or any other attention seeking play things (e.g. iPad). The kids were told to either wait 5 minutes and get 2x marshmallows, or eat 1 marshmallow within 5 min. In a series of hilarious and cute videos (check out YouTube) of little kids doing various maneuvers to delay gratification for a bigger reward (e.g. licking the marshmallow without eating it, and distracting themselves), we see something more profound emerge decades later. The minority of the kids who successfully delayed the 5-min collectively achieved higher level education, higher pay and higher successes than the majority, who failed the marshmallow test, and gave into their system 1 natural tendency to eat the sweet and delicious marshmallow immediately. More importantly, and the key message of the study was the 2nd phase of the study. The research team taught kids mental hacks to help redirect their attention, and practiced these exercises with the kids. In subsequent studies, the kids who received the attention training did significantly better in all the measures compared to their baseline. Nowadays, this study has major implications on the attention of kids growing up with iPads and uncontrolled access to YouTube, where their attention and concentration is drawn to most attention-seeking videos often displaying behaviors that taps into our natural, hard to control tendencies (system 1).

Our ability to control our attention and direct our concentration is the engine that drives our mental well-being. We have baseline levels of control we are born with, and we can cultivate the control through practice. Mindfulness is housed in System 2, and can be easily hijacked by system 1. For example, if something disastrous happens (e.g. our child was in an accident, or fall in love), then we can no longer think coherently and rationally. Our system 2 (higher level thinking) malfunctions due to a tremendous amount of signal from system 1 (lizard brain), suppressing any ability of system 2 to regain control. In the same way, extreme and intense emotional experiences (e.g. anger, depression, love) can make us vulnerable and lead us to make poor choices, say unintended words, entertain terrible thoughts and take regrettable actions. 

Acknowledging this Achilles heel common to all of us, how do we protect ourselves? How do we strengthen system 2 (higher level of thought) and protect it from being hijacked? A simple and easy way is to practice meditation. Meditation consists of putting our attention on a fixed object, and then concentrating on that object over a period of time. A timeless fixed object is our breath. The advantages of the breadth is that it's accessible, and always with us. Others focus on the heart beat, the ticking clock, the feel of the air on your skin, etc. You can also focus on things beyond our senses too, like loving kindness, empathy, compassion. The basic concept is to sit, cross your feet, close your eyes, and set your attention on something (e.g. your breath) and sustain it (concentration). Meditating is like running, remember to keep your expectations appropriate to your level to avoid being discouraged. With time and practice, we can develop our stamina and gain benefits from this exercise. The endurance, speed and stamina will develop over years, not hours. We know meditation works. After 6 weeks of practiced meditation, functional MRI studies demonstrate both increased activity AND volume in important brain centers like the amygdala (our emotional traffic control center).

The benefits of practicing mindfulness are subconscious, and not apparent to conscious mind. When I lift weights, I can feel the muscle pain after a work-out; however, we do not have the same sensory receptors in our brain, so we do not have the same tangible bodily sensation after meditation. I started meditating during residency. I was studying for the radiology boards, and my stress was 11/10. I came across the book, The Art of Learning by Josh Waiskin. His thoughts of performance resonated with me, and I found out that he's a devout meditator. He and other other high performers like Ray Daylio, Steve Jobs, John Lennon, all regularly meditated. Even though Buddha vehemently advocated for us to meditate, the activity in itself is free of religious connotation. I started meditating for 1 minute. Meditation is.the.most.underwhelming activity for a novice. I am accustomed to the feeling of getting things done. Meditation did not give me that rewarding feeling. I guess if you want to know if meditation is working, you can get a functional MRI exam before and over time like the Hopkin group did when they studied the effects of meditation. In addition, meditating is really hard. Keeping my attention on my breath for a period of time took practice. Thoughts, to-do lists, ideas floated into my head. When distraction happens to you, remember that meditation benefits the most distracted minds (that's me, you, and everyone like us). Guided meditation, for example offered through Headspace app, is another way to get into meditation. Headspace is a good app. After a while, I abandoned the app and was able to practice on my own, no longer needing to put the extra steps to find my phone, and turn on the app.

Since starting to meditate about 7 years ago, I can now practice meditation for about 20-30 min everyday. To give you a comparison, the Dalai Lama meditates for 5 hours every day, the first thing in the morning. He wakes up very early (like 3 or 4 am), and meditates till 8 or 9 am (read his Joy's amazing). I've benefited significantly from the positive impact of meditation and would argue the inflection point in my life and career occurred after starting this habit. The slope was gradual and very subtle but over the past 7 years, the trajectory has been striking.

Just as we have different levels of running (5k, 10k, half marathoners, marathoners, ultrathoners, etc), I came to realize there are increasing levels of mindfulness. In Indian and Buddhist traditions, "Samadhi" refers to the highest of the 3 states of self-collectiveness, a luminous mind which is "equanimous and mindful". The first stage is Dharana, being able to hold your attention on an object over long periods of time free of distraction. For example, being able to focus on the breath. The second stage, Dhyanam, occurs when there begins to be a relationship between the mind and the object of attention. You gain insights about yourself from concentrating on the object. For example, by meditating about loving kindness, you gain insights about your ability to process these experiences. The third and final stage is Samadhi. With Samadhi, you and the object become very close, as if they have merged. At that point, the mind sheds its conditioning and the object shines forth as it is. For example, if you meditate about loving kindness in the state of Samadhi, you take on the qualities of loving kindness. At this point, we can see things for what it is (neither good nor bad) and see ourselves for who we are. Ultimately, meditation is about removing our conscious and unconscious biases, and refining our perception like wiping of the dust surrounding a transparent crystal (reference

Regarding Mental Immunity and the pendulum of emotions, what we know is that through practiced mindfulness, we develop our system 2 (self control, emotional regulation, etc), and can develop a mental immunity, of sorts, to the fluctuations of life, and reign in our system 1 (natural, automatic, reactive tendencies). We can narrow the swings of the pendulum a little bit over time and develop our higher order systems (calm ourselves), and rise above these struggles, and recognize them for what they are, rather than become emotionally linked and reacting to them (which we naturally do due to system 1). All of this feels unnatural and takes conscious effort. Eventually, we recognize failures and success as equals, and stay level headed and calm, like the stillness under the surface of the ocean during a thunderstorm. Major struggles no longer cause us emotional harm, and major wins no longer make us elated and high. We remain grounded, at peace, and immune.

Friday, February 4, 2022

Move On and Move Forward

These two past COVID years have been among the most formative years of my life and tremendous amount of growth that occurred. Up until then, we lived predictably and in someone constant state. After COVID struck, so much changed and most importantly, the pandemic tested us, our resiliency, our agility and adaptability.  As with challenges in our lives, when we can overcome them, we grow and become stronger.

As with many other parents, school closure meant our young (and older) kids now at home, isolated from their friends and away from the playgrounds. The first few months of my daughter's virtual online school period created chaos for me. She was 8 years old and completely disengaged from the multiple hours of zoom.  I get fatigued after 1 hour of zoom and the thought of my daughter spending multiple hours everyday online crushed me. In addition, the energy she would otherwise have been venting in the playground got transformed indoors into difficult and restless behavior. Instead of understanding, I became frustrated, exasperated and some days, angry. At some point, I had a shouting match with my 8 year old. That night, I paused and reflected. What is wrong with me? She is a child. I needed to get help and I did. I googled and found out there are parent coaches, paid psychologists who help parents identify and use effective tools.  I found and got a parent coach and we started weekly coaching sessions to help me draw boundaries, set expectations, and improve my interactions with my daughter. It helped about about 30%. We skipped morning class so that she can get outdoor playground time, and set activities in the afternoon to keep her active. We set routines to help develop good habits. My frustrations improved too....also about 30%. But, I was still very highly tense, and well above my pre-COVID baseline.

Around that time, my daughter had been taking the Buddhist class on Zoom over the weekends (previously in person), and I listened in on the teachings and became curious.  I bought the Dhammapada book and started reading it. Ever since, I've completely transformed. One month after reading the book, I stopped needing parent coaching altogether. It was amazing. My parent coach couldn't believe how quickly I transformed after a couples weeks, even though little had changed after many weeks she had been coaching me. All the negative feelings completely dissipated. One of the key teachings the Buddha taught that changed my perspective on my situation was a story he told. Imagine that a catastrophic event happened, perhaps an accident, or in our case, COVID. The event has taken place and that itself is terrible. Then, you hear about the event and all of a sudden, you react negatively and severely to the event. The emotional/mental response inflicts major harm on you (e.g. sadness, depression, despair, anger, etc). It's not the event that inflicted the harm; it's us and our emotional reaction to the event that caused us harm. Buddha explains that you can disassociate these events. Although the event and response are linked, we can unlink it like unlinking a chain. We have control of how we respond to the event.  In my case, my daughter was doing virtual learning which leads to various changes in my daughter's physical and emotional wellness. In addition, I let all of the changes cause me frustration, impatience, and anger because she was not meeting my expectations. This latter component is under my control.  Instead, the better alternative is to accept that things are bad and it is. COVID sucks.  In addition, I can choose not to let it affect me, disconnect the event and my emotional state. This simple understanding rescued me from the rabbit hole I was going into. I recalled this whenever I find my emotions welling up and then, intentionally let it go, and dial down that part of me which I control.  Impatience, exasperation, and anger only lead to poor outcomes and there is no place for it, even if it is justified. It's like the quote, darkness doesn't take away darkness, only light take away darkness. These negative emotions are like darkness and only keep us deeper in the dark spaces. Even when justified, these negative feelings will never bring us peace and joy just like darkness will never shed light. So, let it go. Move on and move forward. I did. Now, I'm grateful for COVID because it forced to learn and apply this simple yet profound teaching which has transformed my life. 


Sunday, May 31, 2020

George Floyd: The Need for Shared Identities

Shankar Vedantam and the team from NPR Hidden's Brain delivers another informative and salient episode on How Our Identities Shapes Health and Educational Success in the context of another act of recent racist violence that has surfaced to national attention. In the podcast, Vedantam addresses the value of how a common race can propel a successful outcome. For example, Vedantam cites health studies that address patients’ compliance with medical doctor recommendations. When a black patient receives the recommendation from a black doctor, the patient is 20-70% more likely to follow medical recommendations compared to recommendations from a non-black doctor. The reason for the dramatic increase in the success is attributed to how patients feel with doctors of the same race: shared understanding. The same findings are seen with white patients and white doctors. The same phenomenon is repeated in education. Elementary black students who have black teachers have a 20-30% increase in test scores. These positive outcomes persisted over decades. The young black children with black teachers have an increased chance of continuing their education, less likely to drop out of school, and more likely to sit for standardized national exams such as the SATs.  A similar pattern emerges with gender. Female high school students with female Calculus teachers are more likely to succeed in math and go into STEM careers. A shared identity (race, gender, etc) is critical for engendering trust and inspiring individuals to follow up and follow through. The shared identity can also reduce negative behaviors. In one example, Vedantam interviewed researchers who demonstrate that willful defiance is markedly reduced when young black high school students have black teachers compared to white teachers. When the teacher asks the student to quiet down, for example, some students will willfully defy the teachers. This defiance may lead the teachers to escalate the interaction and send the student to the principal office. However, when black students have black teachers, the incidence of willful defiance dropped by over a half.  The reason is traced back to the black student feeling of a sense of trust with a black teacher because of shared race and common understanding. One black interviewee remarked, and I paraphrase, “a white person can tell me they understand, but when a black person tells me they understand, I know they really understand.” 

This begets the question about addressing important social issues such as education and health by matching patients/students with doctors/teachers of the same race or gender. Some may interpret this matching as intentional segregation. We’ve spent centuries overcoming gender and racial segregation and strong scientific evidence support racial / gender matching to help us get our desired outcomes. Here, Vendantam makes a great point. With these types of important outcomes (e.g. education success of our children, health wellness of our communities), peoples’ willingness to be active participants of their lives is dependent on trust with the providers of the services. As Ruth Bader Ginsberg stated in her book "My Own Words" addressing Affirmative Action for college entrance, the common theme is about the intention. When the intention of the policy is to connect people, and build trust, then these interventions are necessary. This type of racial matching is distinct from the historical racial segregation because the intention is to connect people and promote a sense of community (NOT segregate people based on sentiments of intolerance or discrimination). When the providers come from a shared background, patients connect with providers on a deeper level that will engender trust and increase the chance of better health.  “Like begets like” adage holds true because “People Like Us” help bridge trust and empathy. 

In the midst of recent alarming racial police violence and xenophobia capturing our national attention, how can we effectively mitigate and address these social issues? We all want to feel safe and protected and we want this for our friends, family, community, and country. It's possible that we can achieve these goals by engendering more trust among people. What can we do to promote trust during these highly charged, high-risk interactions such as interactions with law enforcement? The answer may be “like helps like”. In addition to racial sensitivity training for all personnel involved, maybe we can increase trust and decrease these egregious acts of racism by matching our law enforcement personnel with perpetrators/victims by race? What if the police officer charged to address George Floyd’s case was a black police officer? How much different would the outcome be? Being sensitive to the larger role of trust and empathy which are at play can help us work towards a more peaceful society, connected by shared interests and similarities rather than differences.  Having more ethnic diversity in our law enforcement, health providers, educators, policymakers, etc, and levering this diversity to connect individuals with similar demographics (e.g. backgrounds, race, gender, age, etc), may help us achieve our desired outcomes more effectively if we desire to live in a more psychologically safe and peaceful place.

Sunday, May 24, 2020

Cleaning 🧹Out the Closet: Making Space

I happened to come across my closet organizer tucked away deep in the corner of my closet. I purchased it many months ago and never did anything with it, until the day I happen to come across it randomly. So, I unpacked it and somehow managed to make just enough space in my stuffy closet to fit it in. My closet is a double-decker with two hanging rods stacked on top of each other to accommodate as much clothing as possible. The original design of the closet was a single-decker and I converted into a double-decker a few years ago after getting the idea from a Pinterest post. I had moved back home from my apartment after finishing fellowship and had more clothes than I can fit into my new room. I had so many clothes in my closet that I had to shove the hanging clothes to get a few inches of space to find a dress. I had a lot of clothes, but I could never find the one I wanted or needed. I had the same problem with my dresser. My dresser was so full, sometimes I couldn't close it completely. It was insane. But, when I needed a pair of shorts, I could never find it in my dresser. 

Now I have a hanging organizer which had compartments, I started to organize my shoes into a few compartments, my scarfs, and accessories into others. It was nice. When I needed my scarf or shoes, I could easily access them. The good feeling led me to slowly go through my closet and dressers over the next several weeks. As I slowly went through my closet, I realized I had not worn many of the clothes for over a year. I had purchased new clothes but never spent the time to re-evaluate the older clothes I had, so I kept adding to my closet. So, I started going through my closet. I made a rule that I will donate any clothing item that had not been worn in the past 6 months. Then, the cleaning started. When I finished, I ended up with 8 giant trash bags worth of clothing, which I dropped off at the donation center. After I cleaned out my closet and dresser and limited the items only to the clothes I wore regularly, I felt like a new person. When I opened my closet in the morning to get ready for work, I realized I could find my work clothes a lot faster than before. I have plenty of room in my closet to move things around. I no longer had to search through the massive amounts of hung clothes to find the one dress I wanted. I felt happier because I could find the right clothes, every time. The funny thing was, I looked forward to opening my closet. It was just a closet, why did I experience such a huge shift? I think it's because I had to use my closet every day. Now, finding my clothes was simplified; I had fewer items to search for. The even funnier observation was that I started looking forward to opening my closet because I knew I could find what I wanted, do this easily and quickly. Letting go of 80% of unused clothes in my closet led me to quickly find the 20% of the clothes I loved and wore routinely. 

This made me think. What if I re-organized my life the way I've re-organized my closet? What if I can unapologetically set a rule to spending my time on people and experiences that I loved and enjoyed, and let go of responsibilities/people/service work which I didn't love?

Saturday, April 18, 2020

Experience of A Fledgling Academic Clinician: Reflections

When I was a radiology resident (physician-in-training), I imagined my early academic life after clinical training to be smooth sailing. It was far from it. It felt more like twists and turns through a maze, unsure of where I was, what direction I was going, and unclear how to overcome hurdles. But through this exploratory process, I learned leadership lessons, met inspiring individuals who provided guidance, and became a more effective academician. The objective of this story is to describe my circuitous path and to provide insights for those pursing an academic path in clinical medicine.

My early career didn’t quite start in academics. At the end of my fellowship (nearly 10 years after I finished medical school), I accepted a private practice job close to home. I moved back to where I grew up and decided to work locally. During my 2 months off between starting my new job and finishing fellowship, I was working on a side project to create a radiology curriculum for my alma mater, University of California, Riverside, which had started a medical school. I was in the position to influence and mold a radiology curriculum for medical students. The curriculum was entirely virtual. During the effort over the next three years, I recruited 6 subspecialty radiologists, who taught radiology using Zoom video conference. I created a 1-mo remote learning curriculum adopting principles of flipped classroom and data driven effective learning strategies endorsed by Make It Stick1 to educate incoming 4th year medical students who will be continuing on to become our future generations of physicians. Nearly 170 medical students have completed the radiology clerkship to understand how to use radiology for patient care. Our methods and approaches were published in a radiology journal, JACR,2 and subsequently presented at our national society meeting, RSNA refresher course3 in education, and is being featured in RSNA News.

First lesson: I found that my side project developing a radiology clerkship curriculum and educating medical students allowed me to impact multiple generations of future physicians. Do develop secondary interests because these side gigs may provide additional sources of meaning and value.

During my 2-month hiatus before starting my new job as a private practice radiologist, my former co-fellow and colleague called me and recruited me to start an academic abdominal position in Loma Linda, California. He knew I loved teaching and research. He felt that an academic position would be a better fit than a private practice job. I was torn. I had committed to the private practice group already, but I knew it offered fewer academic opportunities. I also didn't want the group to be upset with me if I changed my mind. A mentor, who I met the following year, provided guidance which captured the essence of what I needed to do, and I paraphrase her advice: "better to deal with the minimal pain now by saying "No", then to deal with a much larger pain later by having said "Yes" to something you didn't want to do." I called the private practice group, and explained what happened. To my surprise, he was very empathetic. The medical director responded "we're sad to lose you, but you need to pursue what makes you happy". Communication is obviously very important, but few of us learn how to communicate effectively. I read an outstanding book Crucial Conversation4 a year before to learn techniques for how to deliver undesirable news, which helped me prepare for this scenario.

Second lesson: I thought my first job was going to be my last. It's not. Opportunities are random. Do learn how to transition from one role to another. Effective communication can facilitate the transition, so that all stakeholders involved are part of the discussion. In addition to Crucial Conversation, I also recommend Getting to Yes5 to improve our communication skills.

I started my job as an academic radiologist at a large tertiary medical center in Loma Linda, California and I felt lost and alone. Several months later, my former co-resident called me to ask if I could present our work on prostate cancer imaging6 at our annual Society of Abdominal Radiology meeting the following year due to her scheduling conflict. I attended the SAR meeting, feeling a little bewildered. Fortunately, SAR started hosting social networking events and I attended a happy hour event. I recognized many of the well known radiologists, but felt a little out of place. But I got over my imposter syndrome and started socializing and meeting new people. I sat down around the fire pit and started chatting with a lady. A few minutes into our conversation, I realized she was one of our newly elected SAR Board Members. Little did I imagine she would become my chair in the next couple of years. I told her I was a new faculty and I wanted to apply for an early career grant. In response, she said “you should meet AS, who is chairing the new committee for early career radiologist.” We walked over and she connected to AS, who would become a strong co-advocate of an online abdominal radiology case conference we started together.7,8 At the same meeting, I attended a research seminar and introduced myself to another well-recognized abdominal radiologist, MSD. Over the next couple of years, he helped me through several research projects9 and formatively shaped my perspective on value-based academic path and life.

Third lesson: Attend conferences where people like yourself convene. Imposter syndrome affects all of us, but put it on hold while you keep moving forward. When talking to people, let others know who you are and what you want. They will either directly help you or connect you with others who can help.

At the start of my second year on faculty, I started to prepare a grant for an early career award. Writing a grant was not a natural talent. Learning a new skill such as writing a grant requires time and perseverance. It was the ultimate test of Duckworth’s grit10. Just like any new skill, having a training program can help. Per recommendation of MSD, I submitted an application to RSNA Comparative Effective Research Training (CERT) program. The CERT program taught me about health services research and guided me through the grant writing process. In addition, I read Ogden Grant Writing book11 line by line to prepare the grant. I took 2 weeks of vacation time in addition to all my academic days and spare time for 3 months leading up to the two grant deadlines. I was emotionally and mentally exhausted. I waited and waited. Then, one day, I got an email “Thank you for your application but we had many great proposals and ….”. My heart dropped to the floor. I became incredibly sad, discouraged and demoralized. My friend called me because he knew how sad I would from the news and I started crying. Thereafter, I had zero interest in writing grants in the near (or far future). One month passed and I had mostly recovered, but then I heard back from the second grant agency “Congratulations!....”. I was shocked, elated and jubilant. The reviewers had a very different feedback from the first grant agency.

Fourth lesson: Writing a grant is skill like any other skills. Do enroll in a formal training or boot camp to obtain this new new skills such as grant writing (and Ogden's grant book is outstanding11). No need to do it alone. Understand that different grant committees have very disparate responses to the same proposal. In fact, research from NIH-funded study findings support that there is low agreement among reviewers evaluating the same NIH grants, which highlights the biases intrinsic in the current peer-review process.12 It may not be your proposal (and definitely not you) whether you are funded or not.

During the same year, I was interested in studying a controversial topic. The topic was polarizing. Some of the stakeholders loved the research question while others were hesitant to study the topic, stating that “the status quo is working; why change it?”. In between these opposite points of views, I didn’t know how to move forward with the research project because I wanted everyone to be on the same page. William Ury’s book Getting to Yes13 really helped. We have to understand our common shared values: why are we here? Through this shared understanding and values, everyone agreed and we proceeded with the project.  During the same year, I participated in a coaching group led by Niel Rofsky and our group critically discussed the book Coaching as Leadership Style14 and role-play scenarios to practice the ascribed techniques. I used techniques regularly to coach myself as well as others through dilemmas. In addition to the coaching group, I independently worked with a coach who I continue to work with today. Both the group and my personal coach have been tremendous in helping to understand my position, my needs, and identify solutions to resolve issues and to thrive.

Fifth lesson: Some research topics can stir controversy, and some people may not agree with the project. I was ready to fold the project because I didn't know if people would agree on the plan.  At some point, you can either succumb to the pressure or find alternatives.  Finding a team of advocates and supporters who believe in the value of work will help you find an alternate path. Learn how to negotiate, and William Ury’s book is a great start. Participate in leadership groups to develop higher-level EQ skills. Personal coaches can help clarify our needs and challenge us to strive to the next level.

Towards the end of my second year on faculty, my responsibilities and commitments started to overwhelm me. I was chairing a committee for a national society, continuing to serve as the clerkship director for the radiology clerkship, mentoring five trainees (medical students and residents) on research projects, had a couple of projects assigned to me by my department, served as a program co-chair for society, while working full time. During my third year, I was invited to give talks at four national meetings, and three of the meetings occurred over a course of 2 months. To complicate the matter, our faculty group got smaller due to a couple of leave of absence. I was losing it and not enjoying myself most days. Then at a national meeting, I bumped into a mentor. She was heading to the gym shortly after our brief meet-up and invited me to go. I joined her at the hotel gym and we worked out. It was great. I came back home and started exercising 2-3x per week. Over the next 2-3 months, I dialed down the pace of the projects, continued to exercise, and slowly my energy as well as my usual happy self re-emerged.

Sixth lesson: I forgot about self-care after I started to get overwhelmed by all the academic efforts. Do exercise, sleep a full night most nights, and make time to rest and recover. A great podcast by NPR Hidden Brain talks about how we can go into a tunnel vision when we are restricted in resources (e.g. time)15. This state of being constantly short of time starves of higher level thinking including long-term planning. To avoid tunnel vision, the key is to plan in advance and then decide early on what one can accommodate. See my blog Short of Time? How to help ourselves.16 Managing our energy levels by scheduling unstructured time, rest & recovery, exercise, and activities we find joy in doing into our calendar are critical for maintaining energy reserves needed for long-term success. The Power of Full Engagement17 and Make Time18 are outstanding books for learning techniques to maintain work-life integration.

I am coming to the end of my third year as faculty and I’m just beginning to feel comfortable with the process, understanding where I want to go, how I want to get there and the pace that I can manage. In the past 3 months, I’ve turned down more offers and opportunities than I have in my 3 years on faculty. I’m beginning to finally understand when people advise us young academic faculty to learn how to say “No”. Being mindful, introspective and thoughtful of who we are and what we can and want to do can help clarify what opportunities to accept and which to turn down. I learned this lesson only after these experiences.

To summarize, I went through several phases. In my first year, I felt completely lost. It’s okay if you don’t know what you want or where you want to go. Build your network at meetings, collaborate with veterans in the field and follow through on your promises. Into my second year, I faced challenges and had to learn how to negotiate to overcome resistance to studying controversial topics, tackle a grant and understand that sometimes, it’s not about you. Learning leadership skills through coaching can move us towards solution-focused discussion. Having a personal coach can help identify the needs and identify ways to address gaps can help achieve a more refined path forward. I rediscovered the importance of self care in my third year as faculty when I started to get overwhelmed by my commitments. Sleep, rest, and exercise power our energy reserve. Hopefully, some of my experiences will provide a perspective for what future early academic clinicians may encounter in their early years. Would love to hear your thoughts.

1. Warren, S. L. Make It Stick: The science of successful learning. Education Review // Reseñas Educativas vol. 23 (2016).
2. Tan, N., Bavadian, N., Lyons, P., Lochhead, J. & Alexander, A. Flipped Classroom Approach to Teaching a Radiology Medical Student Clerkship. J. Am. Coll. Radiol. 15, 1768–1770 (2018).
4. Patterson, K., Grenny, J., McMillan, R. & Switzler, A. Crucial Conversations Tools for Talking When Stakes Are High, Second Edition. (McGraw Hill Professional, 2011).
5. Fisher, R., Ury, W. & Patton, B. Getting to Yes: Negotiating Agreement Without Giving in. (Houghton Mifflin Harcourt, 1991).
6. Tan, N. et al. Pathological and 3 Tesla Volumetric Magnetic Resonance Imaging Predictors of Biochemical Recurrence after Robotic Assisted Radical Prostatectomy: Correlation with Whole Mount Histopathology. J. Urol. 199, 1218–1223 (2018).
7. Chow, R. A., Tan, N., Henry, T. S., Kanne, J. P. & Sekhar, A. Peer Learning Through Multi-Institutional Case Conferences: Abdominal and Cardiothoracic Radiology Experience. Acad. Radiol. (2020) doi:10.1016/j.acra.2020.01.015.
8. Armstrong, V. et al. Peer Learning Through Multi-Institutional Web-based Case Conferences: Perceived Value (and Challenges) From Abdominal, Cardiothoracic, and Musculoskeletal Radiology Case Conference Participants. Acad. Radiol. (2019) doi:10.1016/j.acra.2019.11.009.
9. Tan, N. et al. Imaging of Prostate Specific Membrane Antigen Targeted Radiotracers for the Detection of Prostate Cancer Biochemical Recurrence after Definitive Therapy: A Systematic Review and Meta-Analysis. J. Urol. 202, 231–240 (2019).
10. Duckworth, A. Grit: The Power of Passion and Perseverance. (Simon and Schuster, 2016).
11. Ogden, T. E. & Goldberg, I. A. Research Proposals: A Guide to Success. Academic Emergency Medicine vol. 3 980–980 (1996).
12. Pier, E. L. et al. Low agreement among reviewers evaluating the same NIH grant applications. Proc. Natl. Acad. Sci. U. S. A. 115, 2952–2957 (2018).
13. Instaread. Getting to Yes: by Roger Fisher, William Ury, and Bruce Patton | Summary & Analysis. (Instaread, 2016).
14. Hicks, R. F. Coaching as a Leadership Style: The Art and Science of Coaching Conversations for Healthcare Professionals. (Routledge, 2013).
15. Vedantam, S. et al. The Scarcity Trap: Why We Keep Digging When We’re Stuck In A Hole. (2017).
16. Tan, N. Short of Time? How to Help Ourselves.
17. Loehr, J. & Schwartz, T. The Power of Full Engagement. Managing Energy, Not Time, Is the Key to High Performance and Personal Renewal. Das Summa Summarum des Erfolgs 199–216 (2006) doi:10.1007/978-3-8349-9251-2_17.
18. Knapp, J. & Zeratsky, J. Make Time: How to Focus on What Matters Every Day. (Currency, 2018).

Saturday, April 11, 2020

COVID19 Pandemic Sparks the Heart of Humanity: Observations of Resilience & Adapatability

COVID19 pandemic has caused a global havoc and started a financial crisis. Despite the awful effects on humanity, people have rose to the challenge and evolved in creative and innovative ways.

Pre-COVID19, our economy was booming, and people were pursuing big plans with stable, strong incomes/returns. Then COVID19 came like a lightening strike and very quickly, everything came to a standstill. Busy streets were empty. Schools closed. Hospitals stopped outpatient services. "Stay at Home" orders went into full effect. Worst of all, many have or are actively dying, and many more are loosing our jobs or having work hours slashed. We are forced to stop and think about the bare essentials and cut out anything extraneous.

But, I am a hopeful optimist and I predict that COVID19 will identify effective new processes, and insights. Over the next decade, these new discoveries will make up and increase the returns many folds beyond the pre-COVID19 state.

Reed Omary's tweet "Constraints spark creativity" succinctly summarizes some of the observations I've made. COVID19 has forced us to step outside of our myopic views and consider alternatives. Technology tools have powered many of these alternatives.

Fig 1: Elementary school issued new rules for online learning.😂
For example, COVID19 transformed education.

Schools moved to e-learning. During COVID19, parents and children together went online to learn. Teachers adapted. Our elementary school teachers used Google Classroom to host assignments, Zoom videoconference for instructions, virtual office hours to answer parents' questions. We got daily briefings about the status of the school and COVID19. In addition, I gained new insights. Being in the background while my daughter's 2nd grade teacher gave instructions on Zoom shed new light. We love our elementary teachers, but watching/listening to her & the other kids during the online instructions made me acutely aware of how grateful I became to the school and the staff. The teachers treated the students with kindness and compassion, while being stern with inappropriate behaviors and imparting life lessons along the way for the students. In addition, new issues arose the school issued new rules for online learning including "Don't take your laptop to the bathroom" 😂 (Figure 1).

Learning became easier and more accessible:

  • National societies released or extended free access to incredible online content free-of-charge
  • Lecturers went online and hosted their lectures for a global audience. 
  • Virtual grand rounds became the new standard for departments. One colleague commented that he had more turnout for the virtual grand rounds than any of the prior in-person grand rounds.
  • Educators taught our trainees using Skype / Zoom to give lectures during rotations and read out studies in radiology.
  • Our own abdominal radiology case conference (@AbdominalCase) went to twice weekly from monthly to serve the need for growing desire by trainees for learning opportunities. Inadvertently, the common desire to learn from each other allowed educators to connect online during virtual case conference.

People connect online given Social Distancing constraints. Late adopters of videoconferencing came onboard and realized videoconferencing allows more people to connect and share.

  • Staff meetings went virtual and more people were able to join. A colleague, who is a chair of a department, shared with me that he viewed faculty meetings as an opportunity for people to connect. But, when faculty meetings went online, he had more turn out and interactions than the in-person meeting. He concluded that maybe faculty meetings do not necessarily to be a social function, and instead social events (e.g. holiday parties) can serve that purpose. More importantly, online meetings serves a forum to distribute information to a wider audience than previously allowable with in-person meetings. 
  • Virtual Happy Hours with our friends and new people popped up. Work-life integration was one click away. I had meet-ups with my friends online. Some hosted virtual dinner dates. The physician mom group (PMG) of Phoenix/Scottsdale hosted Saturday 5pm happy hours for us to connect with other PMGs in the area.
  • Fig 2: Generation alpha leverage technology to connect and collaborate.
  • Virtual Playdates allowed children to spend more time with each other. My daughter met her classmates everyday for several hours during Spring Break and regular schooldays to play online Animal Jam together (Fig 2). She works together on multi player game with her classmates during virtual playdate. Generation alpha are digital natives, who are growing up leveraging technology in a new way and COVID19 has highlighted their resilience and adaptability.

Fig 3: Our leaders reveal their superpowers during COVID19.
  Image Credit PicsArt
Leaders rose to the challenge.  I was on a virtual meet up with a coaching group recently and we went around sharing our perspective on COVID19 at our respective institutions. The responses were mostly of struggle or adaptation, but then, one of the individuals, who is a Vice Chair of Operations, commented and I summarize what he said: "it's fantastic. This is what we were trained for and it's great to be able to serve and do what we have been preparing to do all our lives".  Leaders are the superman/superwoman. When the time calls for them, they remove their daily professional clothes and reveal themselves to rest of us (Fig. 3). In the hospitals, our clinical volumes dramatically dropped, in the range of 70-80% depending on site. This has caused a major financial struggle for hospitals to maintain daily needs.  Our administrators have taken the brunt of the workload behind the scenes to carry us through. They meet daily, 7-days a week, strategize as new information flows in, organize, re-organize and plan accordingly real-time to adapt to the crisis and the impact it has had on the health system. Our leaders help us balance both the new clinical needs imposed by COVID19 and spread out the financial strain to the collective. I became ever more grateful for incredible leadership in my department to provide transparency, as well as hope, while emphasizing flexibility and adaptability for all of us. Given the uncertainty and without knowing the gravity of the financial crisis, leaders inspired us and provided realistic hope and optimism encourage us to stay calm and ride the storm.

Fig 4: Service to others during crisis helps us all.
Image Credit: pomocnadlonwschowa
People serve others in need during COVID19. Working parents (including me) were scrambling with childcare because our children were home full-time. Parents had to find new childcare coverage, which became harder because fewer childcare providers were willing to give care due to social distancing. Childcare centers closed. Babysitters stopped babysitting. During these times, the medical students organized themselves to provide childcare services to serve the healthcare workers. Several medical student volunteered to babysit my daughter.  But then, when Arizona issued Stay at Home order at the end of March, I followed up with a student who was scheduled to babysit to let her know I'll figure an alternative. In response, she wrote to me "[medical students] have found that caring for the children of healthcare workers is classified as essential, so I would be comfortable providing that if you need it". Peoples' values surfaced and behaviors became driven by intrinsic motivations (e.g. to serve others) rather than extrinsic motivation (e.g money) (Fig 4). Medical students have been at the heart of these intrinsically motivated behaviors and actions, which makes me so proud to be an educator contributing to developing our future generations of physicians.

In conclusion, COVID19 will leave its mark on humanity and I believe 10 years from now, we will look back and realize COVID19 will have been the strike that sparked the fire of human ingenuity, creativity, innovation and brought out the best in us.

Sunday, September 8, 2019

Short of Time? How to Help Ourselves

Shankar Vedatam, the host of NPR Hidden Brain podcast, recently discussed the Scarcity Mindset in the episode entitled Tunnel Vision. Vedatam discussed three scenarios of scarcity: time, food, money.  In each case, the individuals responded in the same predictable way: becoming fixated on the resource that was scarce and failing to consider larger strategies that would help us out of the situation. Whether we are a busy person short of time, a starving person searching for food, or a poor person lacking money, all three scenarios lead us into a tunnel vision (scarcity mindset). The podcast resonated with me because the scarcity of time is an epidemic for professionals like myself who balance clinical, education, and research duties while trying to maintain a work-life integration. Over the past two years, as an assistant professor, I found myself in a quandary. I tried various life hacks, tips & tricks to become more efficient while at the same time trying to figure out what to focus on and let go. In this blog, I explore the forces that shape our time and the negative effects of the scarcity mindset. Lastly, I review strategies that have been studied and tested that work to curb the negative effects while accomplishing our goals. 


When we are in a scarcity mindset, our minds shift our attention to attaining the resource of interest and thereby, we commit two fallacies that damage us even more:

  1. Attentional Neglect: forgetting about less pressing issues
  2. Borrowing: We borrow to meet at immediate need while failing to recognize the costs 

For example, if we have a paper due, we’ll focus on our attention on the paper and forget about the lecture the following week. Many times, we’ll ask for an extension or “borrow” time from our personal/family time. Over time, these “loans” snowball and can lead to dire outcomes (e.g. strained relationship, distance with children, deprived social life). Yet, at the time we take these loans, we can only think about the benefit to address the immediate need and often fail to recognize the cost (e.g. divorce, arguments, etc). In the same way, the same justification leads poor people to borrow at unreasonably higher interest rates (upwards of 800% interest). We may be quick to judge a poor person to taking high-interest loans, yet fail to acknowledge the same dynamics drive the choices we make when we are short of time, and subsequently take loans from the time with our loved ones. If we are constrained, some argue it is better to do the best we can rather than take loans. Shah et al demonstrated that subjects with a scarcity mindset who did not have the option to borrow fared better than those who had the option to borrow. In the study, subjects with a scarcity mindset (who could not borrow) scored more points on a game than those who could borrow. The inability to borrow forced individuals to focus on the task at hand and effectively allocate resources to achieve the outcome compared to subjects who had to option to borrow resources and scored fewer points. So, if we’re short of time and we have an upcoming deadline, the best course is to focus on the project to meet the deadline because we’ll be more resource-efficient and effective with the fixed time. But this is not the long-term solution. 


Why is scarcity mindset so devasting? People with a scarcity mindset had worse emotional and cognitive states than those with an abundant mindset. Huijsmans et al(Huijsmans et al. 2019) found that people in the scarcity mindset reported more stress and lower confidence than those in an abundance mindset.  Lower confidence may hold back people from making bold decisions, taking risks and being more creative. This fear precludes us from opportunities and breakthroughs which would otherwise improve our circumstances. In addition, Shah et al found that people with a scarce mindset spend more energy, performed worse, and become cognitively fatigued faster than those with an abundant mindset. “Cognitive overload” explains the worse performance. Cognitive overload is a state of mind when our attention is wholly focused on the resource, and as a result, we cannot process other concurrent needs. For example,  let’s consider our internet bandwidth. When we’re downloading a large file and it’s consuming most of the download speed, the computer cannot download anything else because there is no bandwidth. In a scarcity mindset, we suffer both psychological stress and cognitive decline. Remember, this is all driven by our mindset. Our minds have become our own roadblocks to progress.
The mechanism of these behaviors was mapped to specific brain regions. Huijsmans et al assessed the neural activities of subjects artificially placed in a scarcity vs abundance mindset using functional MRI and found that scarcity mindsets increased brain activities in regions of valuation and decreased regions of the brain associated with goal-directed decision making. Individuals with a scarcity mindset focused more on immediate needs and less on higher-order planning. 


How can we help ourselves and keep ourselves from entering the tunnel vision of the scarcity mindset? Fernbach et al discussed two strategies that people employ when constrained: 
  1. Prioritization planning: focus on important tasks and let go of less important tasks, which requires us to trade off one goal for another. 
  2. Efficiency planning: stretch out the resources. For example, if we’re short of time, we may consolidate all of our shopping trips into one trip instead of multiple trips to save us time. Another example is coupon clippers who clip coupons at the expense of their time to save money. 
Fernbach observed that people often react with a mix of both. However, prioritization leaves us feeling bad because we are not able to have everything we want while efficiency requires more time and energy. Fernbach gives an example of packing. If we’re going on an international trip and we have to pack a large suitcase, we’ll pack all our items without thinking. If we were told we only have one carry-on suitcase for the same trip, we will be more mindful of what we pack. We may exchange our gym clothes for an umbrella (priority planning) which feels like a loss and/or we may consider packing more efficiency (stuffing our charger into our socks) which requires time and effort. Priority planning requires us to step back and think about what’s important to us while efficiency planning is trading one resource for another.  

In the study, Ferbach found that subjects prefer to employ efficiency planing over prioritization. With efficiency plans, subjects felt like they were not giving up the original goals; in fact, subjects felt efficiency plans was free, but took more time and thought. Overall, subjects reported they accomplished the desired outcomes more and had more savings compared to subjects employing priority plans. The findings suggest that we prefer to trade one resource for another (e.g. more of our time to stuff charger in our socks) rather than tradeoff priorities (e.g. pack our shoes in place of an umbrella).

But efficiency planning only works so far. When our resources are severely constrained (e.g. we have a lot less time than we predicted), then prioritization become critical. Going back to the packing example, if we were given only a handbag to carry on the plane instead of a carry-on, we would pack only our passport and money (and leave behind our clothes). The impact of the strategy employ also depended on how frequently the event would be repeated. Efficient planner rated higher savings than prioritization planners with repeated events compared to one-time events. For example, as a medical student radiology director, I give on average about 12 hours of lectures per clerkship rotation. I can record these lectures for offline use which will take up a lot more time initially, but on the longer term, it will save me time with each class of students that come through.  This would be an example of an efficiency plan saving me more time in the long run. In contrast, I can choose between attending a family wedding or an important radiology conference. For one-time events, priority planning (e.g. attending an important family event) has higher gains for me than trying to do both through efficiency planning. Typically, the outcome of priority planning will differ more from original intention compared to an outcome from efficiency planning.
However,  both strategies are limited and are often insufficient. Fernbach found that people who employed efficiency plans often were late to prioritize when the resource became even more limited. In fact, people started to react dysfunctionally when resource limitation became dire. Dysfunctional responses manifested in two ways: “what the hell” effect and “choking” under pressure.  In other words, people responded by either quickly moving through our tasks (and not be effective or performed with poor quality) or people became demoralized and give up altogether when our efforts seem fruitless. When people employ prioritization and efficiency planning strategies, they react dysfunctionally when the stakes were higher (e.g. less time, less money, less food).

Instead,  Fernbach recommends resource budgeting before consumption. Budgeting is a form of priority planning that can avoid dysfunctional behaviors while maximizing desired outcomes. Budgeting (with planning ahead & resource allocation) work through the following mechanism:
  1. Decrease ambiguity about what needs to be accomplished
  2. Gives a mental reference point to track one’s performance
  3. Provides clarity of the budget (“implementation intention”) and hence, we're more likely to follow through when cued.
  4. Enable consistency. When we pre-commit resources, we are motivated for internal consistency between planned and executed behaviors

Fernbach found that budgeting before consumption has twofold effects:
  1. Increase prioritization behavior 
  2. Decrease dysfunctional behavior
When subjects were told to plan (budget) their time to maximize the most points in the game, they performed significantly better compared to the group who not plan ahead. Subjects shift their strategies to prioritization over efficiency when told to budget/plan compared to the control group. When subjects carried out the tasks, subjects were more efficient. Even more, budgeting impact was far more impactful for subjects who were more constrained with the resource. For high-level professionals who are highly constrained for time and resources (balance patient care with academic responsibilities and family needs), pre-planning plays an even more critical role.

As a junior faculty over the past two years, I have come to realize the most important aspect of staying in control is planning. Early on, I accepted projects and proposals without thinking about how it fits into my schedule, responsibilities and pre-existing commitments. Recently, I tallied up hours I spend on educational, academic and committee efforts and discovered my non-clinical responsibilities probably accounted for 50% academic time (my actual time allotted was 20%). I was constantly borrowing from my personal and family time. I enumerated the hours I spent on meeting with medical students, research projects, services related duties and discovered a major discrepancy between my actual vs. the time I had. Going forward, I dedicate two days of the month for service-related activities & meetings (10%), and two days for research activities (10%). I also implemented an organization software (Microsoft OneNote) to track all my projects and log the time allotted and how I compared to what my target is. I spend 4-5 hours per week on planning activities. Going through these planning exercises has made it easier for me to determine how new projects would fit in with my current schedule, helped me identify potential conflicts in my schedule and improved how I triage new projects/ideas.

In conclusion, we are all short of something (e.g time, money, space, etc) and it’s very easy to fall into a scarcity mindset when we become fixated on the resource we are lacking. A scarcity mindset sets us down a negative spiral that only exacerbates our conditions. Budgeting our resources (e.g. time, money, etc) will allow us to avoid a scarcity mindset and accomplish our desired outcome by helping us prioritize more effectively and allocate resources more efficiently.