Wellness Committee

Reflections on 2020, Aspirations for 2021 – With a Science of Well Being Lens

Posted on Dec 1, 2021 in Wellness Committee | 0 comments

Reflections on 2020, Aspirations for 2021 – With a Science of Well Being Lens

I was feeling the weight of 2020 last week when I went to Ms. K, a patient who has had a particularly rough year.  “This is the year I lost my leg in the spring, and now, I am losing this battle with lung cancer all on top of Covid-19,” she said, “but I learned something this year, too.  I learned we all need each other, and we all need love”.  As she said this her eyes brightened and the heaviness that pervaded the room lifted and I felt a warmth in my chest.

“Yes, you are right, Ms. K,” I said, “We have learned some important things this year.”

“2020 = a dumpster fire” “2020 = world turned upside down”.  Taking my cue from Ms. K, I have been trying to see it rather as a world revealed. A world where we have a newfound appreciation for relationships and community.  A world much more fragile then we had understood it to be.  A world that needs our tender attention.

We may understand these things, but how do we move forward when so much tough stuff is still weighing us down?  Leaning on the research in social and cognitive sciences, I try to remain optimistic. It is in our DNA to care about the person in front of us and our community.   What we need now are cognitive nudges first to foster our own wellbeing and then our relationships with others.

Here are some ideas that people have embraced in 2020 that we can all explore moving forward in 2021.

Humility: We were humbled by the virus scientifically and socially by our threatened institutions.  And as it turns out, being humbled can be a good thing. There is a rich body of research to suggest that humility first makes us question our assumptions; then often this leads to listening to other people’s ideas and a less “self-focused” outlook.  Gratitude and a greater sense of connection with others follow. Humility is a good first step in self-compassion which can be very helpful in dealing with personal setbacks. 

Research has demonstrated that humility can be cultivated.  As clinicians to whom people look for answers, humility typically is not something we spend time developing. Given that we have all had a good taste of it in 2020, now is a good time to truly work at incorporating humility into our way of being.  And it starts with quieting our inner voices, deeply listening and letting go of some of our assumptions.

Compassion: Across the world Covid-19 wrought tremendous suffering and everyone felt the pull of compassion which is defined as sensing suffering and moving to address it.  Witnessing the compassion on social media moved us all weather this was images of people visiting isolated neighbors or the cheering of health care workers.  Those of us lucky enough be providing health care, we were inspired by our colleagues moving toward danger to express their compassion.

As providers, compassion is foundational in how we move through our world and should be our greatest source of inspiration and energy.  But what I call “the healthcare compassion paradox” can easily get in the way of the natural flow of compassion.  In order to feel compassion, one must witness the suffering of another.  All too often, we rush to the diagnosis and the treatment and miss this crucial step in generating compassion. Take a moment to open your heart and quiet your mind when you first see your patient; their story will inevitably provoke compassion that will sustain you through the encounter and give you energy going into the next.

Awe: Awe is the feeling we get in the presence of something vast or beautiful that challenges our understanding of the world. It is something we depend on the keep life fresh and in 2020, those vacations to “awesome” places like New York or the Grand Canyon didn’t happen, and this contributed the flat feeling we all experienced. Awe makes us feel more alive, but importantly, it also makes us more humble, generous and less self-centered.

This year researchers from UC Berkeley and UCSF demonstrated that awe can be cultivated, and we don’t need to travel the world to find it. A group of seniors were randomized to go on a brisk exercise walk or a walk where they were told to move more slowly but look carefully at their surroundings with a wonderous, aesthetic eye. Those on the “awe walk” reported a greater increase in wellbeing than the exercise group.   So, if we are looking for awe, we can find it nearby if we take the time to look for it.   People can be a great source of awe, too. With some attention, we can find awe in the beauty of our patients’ struggles; this can be another way our work can energize and inspire us.

Here is the link on how to do the awe walk yourself.  https://ggia.berkeley.edu/practice/awe_walk

Purpose: A decade of research confirms that a meaningful life or life well lived has plenty of joy, but more important is living with purpose.  While we are all a little joy deficient now, 2020 certainly made up for it with opportunities to live with purpose.  Purpose is an abiding intention to achieve a long-term goal that is personally meaningful and makes a positive mark on the world. Wearing a mask, staying home in the spring and over the holidays, seeing our patients despite the risks: this is living with purpose. We are leaders who daily work to promote the health of our patients and community. Never has the importance of this work been clearer.

But living with purpose requires stating our purpose.  As with compassion, purpose is so built in our work that we can easily fail to appreciate it.   I have made friends with a former patient and every week he texts me, “Have a beautiful day on purpose!” After each text, I feel energized and approach my work with a more open heart.  We all need reminders like this.

Love:  As we know now, about the only bright side of2020 is our greater sense of our shared humanity and with that, a greater sense of concern for others and need for connection.  This is an opportunity we shouldn’t miss to build upon.  To promote the health of patients and communities, we need to take the next step to make sure we all learn from this insight. We must use our platform in our communities and exam rooms to promote what people now intuit – that an open-hearted, connected world is a healthier one. We need to talk about love.

I am not talking about romantic love but love as defined by Barbara Fredrickson: a moment-to-moment experience of warm, mutual caring that we feel with any person – even strangers – in everyday interactions.  What she also calls more dully “shared positivity” creates a mutual sense of wellbeing. According to her research, our brains are wired to look for this love and if we have this mindset, we can see the world as a source of expanding connectedness and wellbeing.  As healthcare providers, by talking about the health benefits of love and encouraging them to “spread the love” we can promote the health our patients and communities.

Each day I saw Ms. K in the hospital, we had amazing, pithy little conversation.  When she was feeling stronger and ready to go home, she said. “Thank you, Dr. Hass for all you have done, and I’m glad you are almost through your 2020.”

“Well, we have all suffered, but we have become a little wiser as a result” I replied. Then I took her hand, gently rubbed her back and looked into her eyes for a moment.  We both teared up as I said, “Along with medical care, I will try to make sure everyone leaves our med center with a little love, too!”

Leif Hass, MD
Wellness Chair – Summit Campus

Nature is good for us: Why I prescribe outside

Posted on Oct 1, 2021 in Wellness Committee | 0 comments

Nature is good for us:

Why I prescribe outside

A silver lining of the pandemic is that many of us have been forced to spend more time outside; we haven’t been able to do anything else!  I have been able to ditch my car and more safely pedal the 3.5 miles on pedestrian friendly streets to work.  One morning last spring, I was reflecting on how good the ride outside made me feel when I walked in to see Mr. T., a 68-year-old with several significant behavioral and medical problems.

Before I could say a thing, he jumped in as if in mid-conversation. “Dr Hass, I can’t thank you enough.  I swear that prescription you gave me mid- Covid lockdown saved my life!”  Nodding, I tried to hide the fact I didn’t recognize him and assumed he was talking about an antibiotic or some other medicine. 

“I was so depressed and isolated”, he said.  “You gave me a prescription to ride my bike to the marina and watch the sunset.  I have been watching that sunset almost every day until I got sick last week.  And the prescription is still on the fridge!  I can’t thank you enough!”

I have been giving out “old school” paper prescriptions for about 2 years now where I prescribe non-pharmaceutical  things that have been proven to make people healthier.  Apparently, I had given him one to get outside and take in the natural beauty of the sunset.

“Thank you, Mr. T.  that means a lot to me.”  I said, “Your feedback really helps!”

I had heard that nature can make people happier and healthier, but embarrassingly, revealing my bias, I envisioned it primarily for more “outdoorsy” people like me, whatever that means.  Also, I assumed it would just a slight bump in the happiness quotient.  Mr. T had shown me that I had underestimated both the impact of getting outside and who could be helped.

I became determined to dig a little deeper to understand the health benefits so I could do more with these prescriptions.

While much of the research has been done in the USA, Japan is where the science has been most readily embraced.  Starting with research on blood pressure and stress hormone levels in the early 2000’s, there is now a medical specialty in Forest Bathing and more than 25% of Japanese partake in the activity.  There are nearly 100 officially sanctioned forest where the benefits have been demonstrated and with guides to help visitors the get the most from their time in the forest. A measure of the Japanese commitment to health through nature is that the director of the ministry of forestry is a social scientist not a botanist.  Trees are seen more as a health resource than an extractable resource

What are the benefits?  Lower blood pressure, heart rate and stress, improved mood and immune function, better sleep and increased creativity.  There are surprising social benefits, too.   During early forest bathing experiments, Dr Qing Li found that after a couple hours in the woods, blood pressure went down an average of 5 points. The effects didn’t end once people left the trees; stress hormones were measurably lower for a week. After 3 days with 2 hours of forest bathing, markers of immune health showed improvement that last 7 days (researchers at the GGSC confirmed this finding in Yosemite!). And of course, almost all the people would say they just felt better, too!

What is forest bathing? It is essentially taking it all in – with all our senses.  In fact, looked at individually, all our senses have a role in nature’s restorative power.

Dr Qing Li’s group found that when people slept overnight breathing in essential oil from the sacred Japanese cedar tree, they reported better sleep and had lower stress hormone levels.  Since then, researchers at Vanderbilt have demonstrated nurses report less stress if this same oil is infused in their hospital workplace.

Sound researcher Joshua Smyth at Penn State has documented decreased the tension in our nervous system as measured by heart rate variability when people listen to songbirds.  It increases with rumble of cars and roar of airplanes.   Researchers with the Nation Park Service found their parks “look” worse when people hear man-made sounds and thus, view noise pollution as an important issue for the parks.  Man-made noise can be more than an irritant. Research in Bonn Germany found that kids at schools subject to a lot of airplane noise have a tougher time learning than those in control schools across town.

We are primarily visual creatures, so it is not surprising that simply looking at beautiful natural scenes makes us feel good.  A heart surgeon at Vanderbilt suspected it did more than that.  Looking at it closely, he found that his patients whose hospital room faced the forest healed faster than those who faced the parking garage. I never knew why hospitals are full of nature scene until I researched for this project.  Strange that this bit of data reached the architects, but not the doctors!

So why is the natural world good for us? The Biophilia Theory suggested that since we evolved in nature, our senses and body rhythms are best suited for that environment. According to biologist E. O. Wilson, there is an “innate emotional affiliation with other living organisms” that makes us calm and comfortable in nature.  The sounds, smells, sights are our evolutionary “happy place” where we can rest and rejuvenate.  We are deeply tied to a world from where have strayed, despite the comforts and safety of the modern world, there is a price to pay for urban living.

Other scientists espouse the Attention Restoration Theory, Rachel Kaplan at Michigan says the “soft fascination” with the beauty of the natural world along with its subtle mysteriousness draws us in.  It is “enticing but not demanding”.  fMRI data by her student Stephen Kaplan showed that looking at nature pictures let the hard-working executive function parts of the brain recover compared to looking at urban landscapes.

Emotion scientists like the GGCS’s own Dacher Keltner believe there is something else going on as well: awe.  It’s that feeling we get from seeing something vast, wonderous that challenges our comprehension; with it our jaw drops, and we get goose bumps as we say, “Awe-some.”  But more than that happens, we have the same physiological effects that are seen as we forest bathing where heart rate and blood pressure drop.  The “awe walks” the Dr Keltner recommends where one slows down and looks for the beauty as opposed to racing along are essentially a way to forest bathe.  Beyond the physiological there are pro-social effects of awe: less concern for self, increased generosity and more cooperation.  This might be why research suggests there is less violence when trees are incorporated into low income housing developments.

So, what do I prescribe now?  Researchers from Finland suggest that 5 hours a month is the minimum to have lasting effects (leave the technology behind or at least in your pocket).  It doesn’t have to be the forest; water, even urban parks, can be healing, too.   For those with the resources, I prescribe breaks to a quiet cabin or tent of at least 3 days once or twice a year.  I also recommend house plants for home and office, microbreaks of stopping work to look out the window or a nature video for one minute and a couple short 5-minute walks even if it is in an urban environment.

But how in our busy lives? Well, the pandemic has helped with that.  Many of us have taken our physical activities and social activities outside.  Skip the gym and coffee house.   A walk with a friend outside is a Greater Good “three-fer”: exercise, friendship and nature all at once.

We should also be thinking beyond of selves.  Access to the natural world is far from equitably distributed.  While access to green space is foundational in public health and urban planning, my country, the USA, is far behind, Japan, Korea, Singapore, and many European countries in efforts to integrate this idea into our society.  Yet through efforts of hard-working citizens, vets can get outdoor therapy for PTSD.  The SHINE program in the Bay Area is one of several park-healthcare collaboratives that get kids out of their tough city lives to nature once a week.  We should all be inspired by these efforts and find ways to advocate for green access as best we can.

We see the effects of this lack of access every day.  Last week, I was taking care of Ms. S, a 58-year-old woman with mental health and mobility issues complicated by poor social support.  She came to the hospital with abdominal pain.  Sitting down and talking to her I could see her mood and isolation were her biggest issues.  Notes in her medical record recommend psychiatric care and medications, but now I start with a different approach.  “What brings you joy, Ms. S?”, I asked.

“Well, I loved my flower boxes I had outside my apartment” she said.   “I planted herbs and flowers.  Tending the plants made me feel good, but the manager said it was a fire hazard and I have hardly been outside since they hauled them away.” Her comments are in line with data on the benefits of touch – hands or feet in the dirt – and wellbeing. There is also a large body of research on the positive social and health benefits of gardening.

Before she went home, our team gave her resources about community gardens and I gave a prescription to bus to Redwood Park and the lake.  While that felt insufficient, at least she felt buoyed that our health care team felt her garden was as important to her health as she did.

This is a lesson we all should learn from Ms. S: don’t underestimate the benefits of engaging with nature.  Researchers repeatedly found we tend to discount the wellbeing boost we get from nature. Coming out of this long public health crisis we all should cherish all the good we can.   I have tried to make this cognitive shift:  every episode outside is an opportunity to access the healing power of nature.  I try to see each tree as an incredible living being and forests, the shoreline and even my neighborhood park as sacred sites for communing with the wonderous natural world and restoring my body and mind.  And when I watch the sun set, I think of what it did for Mr. T.

Leif R. Hass, MD
Summit, Wellness Chair

Tragic Optimism vs Toxic Positivity

Posted on Sep 2, 2021 in Wellness Committee | 0 comments

Tragic Optimism vs Toxic Positivity – it is important to find meaning in hardship rather than try to gloss over life’s realities, especially when times are tough!

Ms. S is a 75 yo who recently lost a child to a violent crime and another to Covid and kidney complications. Now she lives alone and has just found out about a lung mass.  During one of our conversations she said, “God helps us find a way when there is no way.”  I got goosebumps, my body’s signal to me that I was in the presence of something awesome.

My younger defiantly atheistic self would have questioned the merits of that answer, but now I see the wisdom of it – even for those of us who don’t believe in a guiding deity.  We can find transcendence in suffering.

 I am a big fan of gratitude and looking for the positive in life, but to be human is to suffer loss.  A meaningful life is derived in large part by how well we grow during these inevitable times of hardship. Covid, climate change, political and economic uncertainty, we are all suffering now or have our heads in the sand.

How does gratitude fit into this idea of “post-traumatic growth”?  Gratitude should not be “I’m lucky for all I have”, but “I am grateful for what others have given me and for the opportunities life has presented for making a meaningful life.” With that comes a desire to give back, strengthen relationships, build culture and grow spiritually.  Gratitude researchers call this existential gratitude: being grateful for all that life brings, both the good and the bad.

Gratitude can help us appreciate the little good things at the fringes of our suffering and also help us face the suffering with a growth mindset.

Loss is a defining part of the human experience.  Fully feeling our losses can tie us to others who have suffered and those who have worked to lighten our burden.  As health care providers, we should all feel grateful for the opportunity we have to lessen the burden of those we care for.  We might not do it through a cure, it might just happen with an open-ended question and a quiet presence that invites sharing of hard-won wisdom.  We can learn from our patients about grace and gratitude – a gratitude with depth.

The day Ms. S went home I took her hand and thanked her. “Your grace amidst suffering is a thing of beauty.” I said.

“Your loving presence might be the best medicine I have on God’s journey.” She said

No Pollyannaish “lucky me’s” or blithely blind positivity.  Just some old fashion thanks for sharing ourselves with each other.

Leif Hass, MD
Summit Wellness, Chair

Summit Physician Wellbeing

Posted on Jun 1, 2021 in Wellness Committee | 0 comments

Cultivating Emotional Balance

  • An Important Strategy for  Coping with Stress and Finding Joy in our Work!

Our work is full of time pressure, life and death situations as well as amazing opportunities to see the depth of the human condition.  We are not taught any strategies the help us cope.  I have stumbled upon a great one.  Dan Siegel, a  Harvard psychologist,  developed this idea he calls  “Name it to Tame it”.

Simply naming an emotion is a great way to get control over it.  Functional MRI show that when we name an emotion the activity of the brain moves for the arousal areas of the limbic system where we really feel the heat of the emotion to the prefrontal cortex where appraisal happens and with this, calming neurotransmitters are released to sooth.   Simply naming the emotion helps put out the fire and gives us some control.  Moving our thoughts away from the source of the emotion to the emotion itself can help stop ruminative thoughts that can be fuel for the flames.

The first crucial step is paying attention to our emotions which, at least for me, I was not in the habit of doing.  Emotions are an embodied phenomenon.  We feel them.  Paying attention to our body is a good way to help us recognize what we are feeling.

Interestingly, when we are feeling positive emotions, naming them helps us appreciated them more; the good get amplified!

Give this a try.  It doesn’t take any extra time and with some practice I am sure you will notice the benefits!

The link below is to a longer essay I wrote on this for the society of hospital medicine.  In it, I describe how I used this technique on a tough day on our Covid unit last winter.

https://www.the-hospitalist.org/hospitalist/article/240455/coronavirus-updates/cultivating-emotional-awareness

And look for more Celebrating our Physicians post in June!

Leif Hass, MD
Summit Wellness Chair

Patient Experience

Posted on Jun 1, 2021 in Wellness Committee | 0 comments

At ABSMC We Live a Life of Purpose!

Posted on Apr 6, 2021 in Wellness Committee | 0 comments

Walking toward our Covid unit at 7:30 on a Saturday morning, I passed a very ill patient being urgently transported on a gurney.  With an RT bagging and couple of all PPE’d-up nurses   pushing, this frantic caravan moved the patient towards the ICU.  When I arrived at the nursing stations a moment later, the team there had just figured out the staffing for the day. “Linda and Marina, thanks so much for staying over and working a double” called out Tola the charge, “And Claire, thanks for staying over to help with that Rapid Response call.” Even the nurses who just arrived already look tired with their glasses steamed up and their shoulders hanging low.

They turned and got to work as I stood still taking it in. These exhausted nurses were getting at it because there was work to be done.

“I wish you all could see it with my eyes.” I said, “You are all amazing and you might not even realize it.  Well, I have to tell you.  Our community thanks you.  The medical Staff thanks you.  Your nursing colleagues thank you.”

“As thanks, let me offer you this.  Something so obvious we tend to forget it around here.  You live a life of purpose! You believe in taking care of the elderly, the sick, the disenfranchised.  You believe that people take care of people, because that is what human beings do, because that is how we build a just and beautiful society. You sweat and hustle and breathe all day through N-95s because that is what a nurse has to do to serve in the pandemic. Looks like we need better staffing and you could all probably use a cup of coffee, but I offer you this because you should have great pride in what you do!  Tell your friends and family that you live a life of purpose.”

A little embarrassed by my preachiness, I then shut up. But I felt compelled to tell them. It is true and it is something we all need to hold in mind as we grind through this awful pandemic. I tried to slink away but the team was energized now. “You are right; we don’t think about it and people don’t often remind us of it either. Thank you so much!”  Phones came out and we did socially distanced selfies.

I had been feeling crispy myself the week before when I got a text from my friend Ray. Ray is a wonderful human being and a person whose life is inseparable from his faith.   Every couple of weeks, I get a text from him.  On that morning the text said, “Have a great day on purpose!”  I had heard that playful pun-like phrase before, but going to work, to work caring for some of the sickest and most vulnerable people in the east bay, it didn’t feel trite that morning; it felt profound.   My purpose was my path to make a potentially tough day a work into a “great day”.

That night, I started doing a little reading about purpose and got even more fired up!  Dacher Keltner who co-teaches UC Berkeley’s class on happiness says, “a sense of purpose is possibly the best predicter of a life well lived.”  Developing a sense of purpose is one of the keys to happiness.  Nothing predicts performance and satisfaction at work as much as having a sense of purpose.  An entire industry has developed to help people find a sense of purpose at work. Why had I lost sight of this sense of purpose in my work?

Turns out that perhaps I had started to fall into common trap. I started to equate wellbeing with thoughts about one’s self. While working on ourselves is necessary, it could be a life time before I get myself “dialed” just right. It seems those community focused, hardworking ideals that got me into medicine in the first place, ideals that seem naïve at times now, are fact right.  Our years of study and training to earn the right to care for the most vulnerable in our community is something to be very proud of and should be a driver of our wellbeing.

Purpose is energizing and motivating.  Purpose won’t empty your inbox or get the OR to run on time, but it can put gas in our tanks, and we all need that from time to time.

Perhaps the purpose in our work is so omnipresent we lose touch of it.  Perhaps it is the relentless emotional content of the work or the irritating administrative tasks that blind us to it as well. Perhaps there is an important sense of humility, too.

Yet we can hold these notions in our minds and hearts at the same time: Ours is a life of service and purpose.  We accept the responsibility with humility and a tender heart. As an institution we should have a sense of full-chested pride.  And with each other, we should remind each other of our purpose.  When we have those late-night phone calls, those tough conversations with patients and those grueling days we need that pride in our purpose to turn our sacrifices into a great day.  Thank you for living a life of purpose and all you do to serve our community!

Leif R. Hass, MD
Summit Wellness Chair