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“He who has a Why to live for can bear almost any How.”  Nietzsche

Viktor Frankl, MD (1905 – 1997) was a psychiatrist who lived in Nazi-occupied Austria in the 1930s.  He graduated from the University of Vienna Medical School, and ultimately became a Professor of Neurology and Psychiatry at that institution following WWII.  Viktor was Jewish, and he and his family knew when Hitler annexed their country that their future most likely would involve being moved to a concentration camp with all of the other Jews, or possibly an extermination camp.  He had a visa waiting for him at the American consulate in Vienna which was his ticket of escape from such a destiny; his elderly parents were overjoyed at his good fortune and wanted more than anything for him to take advantage of the opportunity to lecture in the U.S. in the field of psychiatry.  He would not avail himself of this option, and instead stayed with his parents to care for them.  The Frankl family was subsequently sent to concentration camps, as feared; Viktor’s parents were murdered by the Nazis, but he survived, though he was held captive for three years at Auschwitz, Dachau, and other concentration camps.  He gained much insight into how fellow inmates either survived or lost their lives.  Though many died by disease and/or the crematorium, he noted that those that lost their hope, their “why”, universally did not survive.  His hope was to one day be reunited with his wife and to be able to lecture on what became known as logotherapy, or the quest for meaning.  Frankl noted that fellow psychiatrist Sigmund Freud postulated that man’s primary quest was for pleasure; another famous psychiatrist of his time, Alfred Adler, proposed that the quest was for power.  Frankl often purported the following:

“Forces beyond your control can take away everything you possess except one thing…your freedom to choose how you will respond to the situation.  You cannot control what happens to you in life, but you can always control what you will feel and do about what happens to you.”

Frankl defined three sources of meaning:

1. Meaning in work
2. Meaning in love (relationships)
3. Meaning in courage during difficult times

He miraculously survived his three years of captivity, giving further credence to his theory of the quest for meaning.  He became the founder of the Third Viennese School of Psychotherapy (with emphasis in the practice of logotherapy).  I highly recommend that everyone read his account in the book Man’s Search for Meaning (Beacon Press, Boston).

I was taught in medical school and residency that you should never provide “false hope” to your patients.  I knew this meant that you needed to be an objective source of realism and not be deceptive in how you give your opinion and advice, especially when it dealt with someone’s ultimate survival or death.  The more I thought about this, however, the more I disagreed with it.  How can there be such a thing as “false hope”?  There is either hope in the future or there is no hope, but in my own opinion there is no such thing as false hope.  While it is very important to not lie to patients, it is equally as important to not take away their hope.  As physicians, we have an incredibly unique opportunity to help people define their own “why”, their own reason for being.

I am often heartbroken when I hear of, or actually see right in front of me, physicians who have lost their why, and who have become “burned out”.  It is exhibited in doctors who seek early retirement to escape; others become addicted to drugs, alcohol, varying degrees of moral turpitude, and (ultimately) some will take their own life in utter despair.  I can see that much of this revolves around a greater and greater loss of control to various forces (as Dr. Frankl described).

Simon Sinek, author of the book Start with Why, illustrates his concepts with what he calls “the Golden Circle” and it is pictured as follows:

It is interesting that the “why” circle is on the inside; everything that moves toward a change away from burnout must begin within and move outward.  I heard Jon Gordon, a lecturer, state, “We don’t get burned out because of what we do; we get burned out because we forgot why we do it.”

These two books, Man’s Search for Meaning and Start with Why have been extremely helpful in my own search for my “why”.  I would encourage you to not only read these very insightful treasures but to find a place for them on your library shelf.

[Verse 1]
There’s no time to kill between the cradle and the grave
Father time still takes a toll on every minute that you save
Legal tender’s never gonna change the number on your days
The highest cost of livin’s dyin’, that’s one everybody pays
So have it spent before you get the bill, there’s no time to kill

[Verse 2]
If we’d known ten years ago today would be ten years from now
Would we spend tomorrow’s yesterdays and make it last somehow
Or lead the cheers in someone else’s game and never learn to play
And see the rules of thumb are all the same that measure every day
The grass is green on both sides of the hill, there’s no time to kill

[Chorus]
No time to kill, even I’ve said it, probably always will
But I can look ahead and see that time ain’t standin’ still
No time to kill but time to change the kind of hurry I’ve been in
Quit this work and worry lookin’ back at where I’ve been
If you don’t look ahead nobody will, there’s no time to kill

[Verse 3]
If we had an hour glass to watch each one go by
Or a bell to mark each one to pass, we’d see just how they fly
Would we escalate the value to be worth its weight in gold
Or would we never know the fortunes that we had ’til we grow old
And do we just keep killin’ time until there’s no time to kill

[chorus]

Clint Black, “No Time to Kill” 1993

This song made my top 700 songs on my iPod, and I have listened to it many times since 1993, originally on the CD that I purchased.  This morning, driving to work, I heard it again.  I realized what a precious commodity time really is (I think we all have a basal feeling about that, but it really struck home).  I ask myself, “have I been a good steward of the time God has granted to me so far?”  The answer is no, I really have not!  I started Michael Hyatt’s program using the Full Focus Planner ™ a little over one month ago, and every day that I have used the planner I have realized to a greater extent how I have let time slip by in so many ways.

Yesterday was a perfect example.  I was raised a Texas Longhorn fan from the moment I can remember, so much so that I do think my blood is burnt orange!  The people who know me (especially my dear wife) might actually shade more toward me being a fanatic.  I was watching the game on TV between the Longhorns and West Virginia, trying to turn over a “new leaf” of sorts….be positive, though the refs were horrible.  Be positive, enjoy the game, though the announcers were obviously jaded toward West Virginia.  Keep my voice down, so that I would not scare our three dogs into thinking the world was coming to an end.  I ended up turning off the TV volume because I was ever so close to losing it and just could not listen to one more word proffered by the play-by-play announcers.  It was nearing the end of the game, Texas was ahead, and all the Texas defense had to do was hold the other team.  Unfortunately for me, the other team scored and was one point away from tying with an extra point kick.  Instead of kicking and going into overtime, West Virginia went for two points AND GOT THEM!  Oh my, the nuclear bomb of my anger in its worst virulent form detonated, and I lost it!  TOTALLY LOST IT!

I can assume many of you have emotional ties to certain things, beliefs, positions, attitudes, and might be able to relate to “losing it” at times.  However, how trivial is losing your wits over a stupid sport or game?  As I look back over the years, I recognize that I justified such behavior as being totally OK, “that’s just who I am….no one else has been in my shoes, has experienced what I have experienced, and if they don’t understand, then they are not extending any effort at all to fit in to understanding my behavior.”  I would categorize such lack of effort as not caring about ME at all.  What a crock!  Over the years, Longhorn wins would lead to “happiness” for at least a little while, a lighter step every day, non-ending whistling of “The Eyes of Texas” throughout the week.  Unfortunately, a Longhorn loss would lead to utter, inconsolable depression, worse than a death in the family!  Knock-down, drag-out fights have erupted between me and my brothers during these down moments; unfortunately, my negative energy during these times has been building so much that my wife finally told me yesterday that it had to end!   Before she uttered the words, I understood that to be the truth; something had to change.

I am not the coach of the Texas Longhorns.  I am not a player on the team.  I am not the athletic director.  I really have no realistic “longhorn” in the fight.  I have no power over the outcome of any game, of any sport.  Where does my power lie?  IT LIES WITH CHANGING MYSELF!!  I only have power over my own behavior, my own reactions, my own attitude.  How poisonous it is to go nuclear around those who care about me and for whom I care?  How much TIME have I wasted in such ventures?

I will be “fasting” from Longhorn sports of any kind for the unforeseeable future; if necessary, forever if I cannot make the changes I need to make.  How wonderful I feel having made this decision, and how increasingly productive will my life become once I quit wasting more time?!

Jerome E. Groopman, MD wrote the book How Doctors Think in 2008.  I saw Dr. Groopman interviewed on the PBS Lehrer Report shortly after this book was published, and I was fascinated by his reasons for writing it…so much so that I promptly bought the book and read it.

He related how, in his teaching position at Harvard, he was exposed to many medical students and young doctors in residency training who were very smart and seemed capable during his interactions with them.  However, he noticed how quickly they seemed to come to a diagnosis after a very short time to consider the clinical picture of any given patient.  These soon-to-be practitioners would anchor in, as he put it……have the diagnosis made without any consideration of other possibilities.  This type of reasoning is also referred to as “silo thinking” and failing to think laterally for other options.

He also hurt his hand while swimming, and it failed to get better after a considerable amount of time.  He experienced excruciating pain while typing on his laptop or writing for any reason.  He saw multiple practitioners to try and get help.  On one occasion, he was sitting in the exam room with his wife (who is also a medical doctor) and the hand surgeon came in the room with his resident, viewed the x-rays, said that arthroscopy needed to be done, and stated that the resident would put him on the surgery schedule.  When asked what would be done, the world-renowned surgeon replied that he would “figure it out” when he got in there.  Needless to say, Dr. Groopman kept seeking out opinions until a younger hand surgeon had him get x-rays with both hands in a certain position and made the diagnosis.  The young surgeon was also honest and stated he had only done one such case before. Dr. Groopman went to a more experienced surgeon and had the problem fixed.  In summary, even he (along with his wife) had to navigate the healthcare conundrum in order to get help.

The book is very insightful in its discussion of our current healthcare environment.  He ends the book with important questions to ask your doctor when being evaluated for any condition:

1. What else could it be?
2. Is there anything that doesn’t fit?
3. Is it possible I have more than one problem?

These questions help to create an opportunity for your doctor to leave the “anchored in” position and provide an opportunity to think laterally.  We are all patients at one time or another, and making the care environment more accepting of questions and further consideration is time well spent.

Jerome E. Groopman has been a staff writer in medicine and biology for The New Yorker since 1998. He is also the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School, Chief of Experimental Medicine at Beth Israel Deaconess Medical Center, and author of five books, all written for a general audience. He has published approximately 150 scientific articles and has written several Op-Ed pieces on medicine for The New York Times, The Washington Post, and The New Republic.

“Practicing regular, mindful breathing can be calming and energizing and can even help with stress-related health problems ranging from panic attacks to digestive disorders.”              Andrew Weil, MD

I once had a patient, a single mom of 2 energetic boys, who worked as an engineer at a prominent Texas high-tech company.  She was on two different antidepressants, an anti-anxiety medication, and was needing to increase the doses continuously just to try to function daily.  She was, understandably, having more side effects from the meds but not having success with her unrelenting stress.  She was on probation at work due to blow-ups with fellow employees, and was informed by her boss that if she was not able to “get a grip, and soon” she would lose her job (which created more stress!)  She sat in front of me, very depressed and shaking, wanting my help.  I went over with her the simple exercise of relaxation breathing, which immediately made the shaking go away, and told her to download Dr. Andrew Weil’s audiobook Breathing:  The Master Key to Self-Healing  available through the Apple Store.  She listened to the book, did the exercises faithfully, and decreased her meds to just one low-dose antidepressant.  She had a marked turn-around at work, even receiving a promotion within 90 days due to a new invention she proffered to management.

A part of our nervous system is called the autonomic nervous system; it controls involuntary functions in our bodies that keep us going….breathing and a heartbeat being the two most important ones.  It is made up of dual parts:  the sympathetic system (fight-or-flight, “sitting on the edge of the chair” system) and the parasympathetic system (the “chill” functions).  Many of us live more in the sympathetic system in our harried day-to-day existence.  Interestingly, breathing is done unconsciously but it can also be “taken over” consciously at any moment, once we decide to do so.  By performing some simple breathing exercises, we can move ourselves from the stressed side to the chill side in mere seconds…you only need less than 5 minutes of your day to get there!

Here are simple instructions on how to do a relaxation breathing exercise:

The 4-7-8 (or Relaxing Breath) Exercise (from drweil.com)

This breathing exercise is utterly simple, takes almost no time, requires no equipment and can be done anywhere. Although you can do the exercise in any position, sit with your back straight while learning the exercise. Place the tip of your tongue against the ridge of tissue just behind your upper front teeth, and keep it there through the entire exercise. You will be exhaling through your mouth around your tongue; try pursing your lips slightly if this seems awkward.

• Exhale completely through your mouth, making a whoosh sound.
• Close your mouth and inhale quietly through your nose to a mental count of four.
• Hold your breath for a count of seven.
• Exhale completely through your mouth, making a whoosh sound to a count of eight.
• This is one breath. Now inhale again and repeat the cycle three more times for a total of four breaths.

Note that you always inhale quietly through your nose and exhale audibly through your mouth. The tip of your tongue stays in position the whole time. Exhalation takes twice as long as inhalation. The absolute time you spend on each phase is not important; the ratio of 4:7:8 is important. If you have trouble holding your breath, speed the exercise up but keep to the ratio of 4:7:8 for the three phases. With practice you can slow it all down and get used to inhaling and exhaling more and more deeply.

This exercise is a natural tranquilizer for the nervous system. Unlike tranquilizing drugs, which are often effective when you first take them but then lose their power over time, this exercise is subtle when you first try it but gains in power with repetition and practice. Do it at least twice a day. You cannot do it too frequently. Do not do more than four breaths at one time for the first month of practice. Later, if you wish, you can extend it to eight breaths. If you feel a little lightheaded when you first breathe this way, do not be concerned; it will pass.

Once you develop this technique by practicing it every day, it will be a very useful tool that you will always have with you. Use it whenever anything upsetting happens – before you react. Use it whenever you are aware of internal tension. Use it to help you fall asleep. This exercise cannot be recommended too highly. Everyone can benefit from it.

Give it a try!  If it does not work, it has not really cost you anything.  However, if it does work, it belongs to you, does not need refills, and it can do wonders for your health now and in years ahead.  Remember….breathe!

Who are the heroes in my life?  That is an easy answer, and only one person has filled that role; my father.  He was one of a kind!  I would go out of my way to emulate him, then and now.

I remember going with Dad to one of his medical school lectures at UTMB in Galveston as a small tyke.  The room was expansive, dark, with the only light coming from the slide projector as Kodachrome pictures of tissue samples stained with H&E went one after the other.  Boring stuff, and a foreshadowing of my future.  I remember being so proud of Dad, of the feel of the medical environment that he brought me into….the mystery of the human body, when it worked well and when it was broken.  There must have been a childcare snafu of sorts for him to have me along that day.  Mom was working 2 pharmacy jobs at the time, and Dad was filling in as a pharmacist at Texas Drug as well, for night shifts.  He forgot I was at his side when the lecture was over, and he was chatting it up with his friends in the foyer smoking a cigarette.  He casually dropped his right hand that was holding the cig, and it burned my left inner forearm by accident as I huddled next to him.  I let out a major wail, and he put the cigarette out as he scooped me up to take me home.  That incident did not deter me from wanting to always be at his side whenever he asked.

There were unique smells in our house, including the smell of the medical textbooks I would open and peruse.  The doctor bag he received at his medical school graduation contained his stethoscope, his otoscope/ophthalmoscope, and a sphygmomanometer (blood pressure cuff).  I loved the smell of medicine, loved playing with the tuning fork that played the C note I would later find out was used for neurologic evaluations.  I would hit it over and over to hear that note, the score of which I would follow later.

Since Dad was a pediatrician, many of my friends were his patients in the small East Texas town of Greenville.  No one spoke ill of him among my classmates, and being his son brought me immediate status with them.  I realized that being a doctor was instant goodwill among most people (as long as you were a “good” doctor).  In the sixth grade, I made up my mind…it was medicine for me!  When my classmates would bring new toys for show-and-tell, I would bring old xrays of my broken arm and put them up to the light and show everyone my right arm fracture.  On one occasion, when a pop quiz over organs of the body was underway, I could not help myself when Mr. Lamb pointed to an organ and (sensing no one else knew what it was) blurting out “pancreas”.  Mr. Lamb immediately scolded me for giving away the answer, as my ADD and occasional lack of self control was exhibited; he did so with a grin and a wink.

The only time I remember Dad asking me to go out for lunch with him alone was during my junior year of college, as I was nearing the end of my own education at the UT Austin College of Pharmacy as a legacy to my Mom and Dad.  I was applying to medical schools, and Dad sat across from me and began to relay the truth of medicine as he saw it.  “Medicine is not what you think it is…it is all about gimmicks.  The gastroenterologists have scope procedures, the cardiologists have cardiac caths, the ortho docs do joint replacements.  That is what drives doctors; the procedures, doing as many as possible to make a living.”  It was not the Hollywood-created persona of Dr. Kildare, Ben Casey, MD, or Marcus Welby MD that I saw before me on television growing up, but at times a profession driven by many other things than care for patients.  “Why don’t you go to dental school?  It is much less stressful, just as honorable, and what I would do if I had to do it over again.”  I replied, “and mess in the mouths of people all day?  No thanks!”  Of course, he had to later rib me about my chosen specialty of OBGyn by stating, “so you didn’t want to mess in mouths all day…what are you doing now?!”

There was one day I will never forget that occurred in the early days of my own medical practice in Austin, Texas.  I was trying to build my own goodwill, my own reputation in the community.  Being the son of Carl Pevoto, MD went a long way toward that goal, since he was well-known and respected by his peers as a trauma physician at Brackenridge Hospital in his newer and ultimate specialty of Emergency Medicine.  Dad (and his fellow ER docs) would call me if an unassigned gynecologic patient came into the ER and would need care.  One such patient came in with an ectopic pregnancy that was bleeding, and I gladly came in to assume her care.  While I was in the OR with my gloved, sterile hands removing the bleeding ruptured fallopian tube that threatened the patient’s life, I glanced out to see my dad standing in the shadows outside the operating theatre I was using, watching me, wiping a tear from his eye as he slinked away knowing I had discovered him observing.  I knew at that moment that he was proud of me, making my decision to pursue medicine the right one.  Dad, I know that you are watching me now from heaven with all of your buddies, and I am so happy that you are proud of me.  I hope that I can likewise be a hero for someone as you have been for me!