Who Do You Know?

A Friend in Pain

As I looked around the table at my physician colleagues and friends, I didn’t recognize her. We started our meeting with introductions, and when she stated her name, I looked up, startled.  The person who was speaking was unfamiliar to me. The enthusiasm and joy that she radiated so clearly a few years before had disappeared. The individual before me was distant and cautious, and in some way that I didn’t understand, traumatized. Even her voice seemed different. I looked into her eyes, but I could not find her.

What had happened? I took a chance and invited her to join me for a cup of tea. We met the next week, and remarkably, even though we did not know each other well, the conversation was easy and relaxed. We quickly omitted small talk and moved to a more pressing issue: the profound distress that she and other physicians in our community were experiencing as they practiced clinical medicine.

She did not guard her emotions; exhaustion and disillusionment had stripped away all pretense. All that remained were raw feelings, and the hope that someone would understand and care. We talked for hours. She described the wedge between her desire to help patients heal and the structures that had been put into place to “measure her value” with numbers.  Number of patients seen, number of prescriptions written, number of tests ordered … Her sincere commitment to her art and compassion for her patients had been relegated to second place behind the numbers.

We met several times, first making space for the expression of pain and grief. She was not looking for answers. Yet, in some way, despite the lack of congruence between her training and the expectations of a changed system, she was still hoping to reconnect with her calling. Slowly, over time, moments of laughter crept in, and we rested in the comfort of our shared humanity. She knew that I understood, but most importantly, that I cared, and this provided a foothold, a starting point for healing.

Many physicians nationwide share similar experiences. They find it difficult to describe the dissonance between their expectations and reality. Yet, the injury is real. Research consistently confirms a critical decline in the health and well-being of physicians. The loss of physician colleagues to suicide has been devastating to our medical community and heightened our commitment to actively address this public health crisis.

A Community Responds

My colleague Ed and I often meet at a little breakfast spot to share ideas and find inspiration.  Long time physicians, we clearly remember a time when physicians shared a genuine enthusiasm for professional work. Most physicians owned their own practices. Extensive administrative demands and regulations did not disrupt the effective practice of medicine, and physicians had time to build strong relationships with patients and their families, as well as their peers, so they could navigate challenges together.

We remember when physicians, administrators and other healthcare professionals worked side by side to provide high quality, compassionate health care to our patients. While we did not always agree on the best way forward, we sincerely respected the legitimacy of each person’s point of view, while actively pursuing efforts to negotiate the differences. On this sunny morning in July, deeply concerned about the well-being of our colleagues, and acutely aware of the complexity of the issues, Ed and I wondered what our small community could do to effectively respond to this crisis.

We were on the cusp of a 2 day Rediscovering Meaning In Our Work retreat conference created to explore the drivers of physician burnout and moral injury and provide a space for physicians and healthcare executives to connect, openly share their experiences, communicate concerns and identify creative, collaborative pathways forward.

In preparation for this event, Ed and I decided to invite friends from several sectors of healthcare to come together to actively address a system-level issue with significant impact on the health of our medical community. If we could make progress in the few months before the conference, we could share the results with our peers, and hopefully, provide inspiration. Our group became known as the Idaho Physician Well-Being Action Collaborative (IPWAC).

For our first project, we chose prior authorization, a process that significantly increases administrative demands on physicians in clinical practice and compromises patient care. Our goal was to bring prior authorization capabilities and medication costs and alternatives to physicians at time of service via the electronic health record. We invited physicians, hospital administrators and insurance company executives with whom Ed and I had established relationships to join the conversation.

While our first meeting was a bit contentious, we have come together every 2 months for over 6 years, and most of the people who started this work with us continue to participate, even after they have moved to other jobs. Each year, new friends in our local community and around the country join us. Many of the participants express that they feel nourished and inspired by our conversations, and while Ed and I facilitate, the success of this work is shared by each person who has contributed.

We have made significant progress. We have reduced prior authorizations by over 50% in some instances, coordinated prior authorization grids and started to build the infrastructure needed to accomplish other goals. Most importantly, we have cultivated a strong network of diverse individuals who openly and respectfully share ideas, insights and experiences with each other, and are committed to doing this work together.

New Projects:

Our community circle is now viewed as a welcoming space where people with different perspectives and experiences come together to effectively address complex and potentially divisive system-level healthcare issues.

In 2023, in response to the changes in the reproductive laws in our state, we expanded our focus to include women’s health. We are collecting and organizing data to detail the impact of the current laws in our state on health outcomes, access to medical care, the physician workforce, medical costs, economic growth and other factors that affect the health of our community. As we build an accurate and comprehensive database and identify important trends, we are sharing the results with our local community and communities nationwide.

An initial report highlighted a significant decline in our physician workforce in the 15 months after the change in laws in our state, with the closure of hospital obstetrics programs, and thus, reduced access to healthcare for all Idahoans. The data in this report has been highlighted in television and radio interviews and included in publications nationwide.  In addition, this research was referenced in a U.S. Senate report entitled “Two Years Post Dobbs: The Nationwide Impact of Abortion Bans.”

We continue to collect data and welcome healthcare and business professionals, educators, legislators and many other community members to join us at our roundtable to explore the research, share their insights and identify innovative solutions.

A Community Healthcare Movement:

In 2019, in collaboration with of a small group friends with broad experience in education and healthcare, we extended our friendship-centered approach to our wider community by creating the Compassionate Communities Healthcare Movement (CCHM). Our multi-generational movement includes seasoned professionals as well as university and medical school students. We work together to rekindle cooperative responsibility for the health of our communities, advance health equity & inspire compassionate action.

This October, the Compassionate Communities Healthcare Movement, Idaho Physician Well-Being Action Collaborative and Ada County Medical Society (ACMS), three organizations deeply committed to relationship-based work, are welcoming Dr. John Paul Lederach to our community. Dr. Lederach is internationally recognized for his pioneering work in the field of conflict transformation, reconciliation and international peace building. His experience highlights the potential for everyday people to shift the trajectory toward peace. He will meet with us at the Wassmuth Center for Human Rights to share insights and strategies that can be applied to current challenges. 

In 2025, Compassionate Communities is offering a Root Down Reach Out retreat conference to organizations and individuals who are working to actively address the impact of wildfires, droughts, floods, heat waves and other environmental events on the health of our communities. Similar to the retreat for physicians in 2018, we will welcome many voices, including those not often invited to the conversation. Local artists, musicians, poets and others community members will help us create a nourishing space to cultivate connection, deepen understanding, inspire hope, and move forward together.

A Dynamic Approach:

Ed and I often receive phone calls from people in other states asking us how we developed a coalition of diverse individuals from several sectors of our community who are enthusiastically and successfully working together to address complex healthcare issues. We have reflected on our experience and identified three integral aspects of our work together that differentiate our approach from more conventional, process-oriented efforts:

1. Cultivate A Circle of Friends

To advance cooperative and effective action, we believe it is essential to nurture and expand our relationships. We integrated an approach to cultural and social change illuminated by Dr. John Paul Lederach, a pioneer in the field of international peace building. John Paul has worked for decades to address violent conflicts around the globe, demonstrating that social and cultural change start when a small group of people decide that circumstances are intolerable. Before they develop a plan to address the situation, they ask each other:

Who Do You Know?

NOT who do you know who agrees with us, but "Who do you know with whom you have a relationship who you can welcome to join our conversation?”

John Paul proposes that our friendships provide an essential, sturdy and flexible foundation as we work to address complicated issues. With friends, we are more likely to listen carefully and respectfully, consider new ideas, recognize our biases and strive to understand each other. Our vision emerged from concern about the declining health and well-being of our physician  friends, so we started by inviting a small circle of friends who share our concern to respond to this crisis.

In an effort to strengthen our relationships, we have integrated two practices. First, we take time at the start of each meeting (and between meetings) to check in with each other, and when someone shares that they are going through difficult times, we provide a space for conversation and support. When caring relationships are prioritized, our work together is organic, creative and meaningful.

Second, we address each other by first names. This simple practice makes it easier to connect as individuals, each with our unique struggles, dreams, and insights, rather than focusing on titles. Doing so also nudges us to consider our attachment to identify and its effect on the quality of relationships that we develop.

Our circle of friends is continually growing. Ed and I encourage each of the Action Collaborative participants to welcome people with whom they have relationships to join us, especially individuals who see the world in ways that are vastly different from their own. At times, discussions among people with diverse opinions ignite strong emotions, but rather than shying away from disagreements, we make space for respectful inquiry into the reasons that we feel strongly about a particular idea. These times are unique opportunities to learn together, expand understanding and uncover shared values.

Friendship is a moving frontier of understanding, not only of the self and the other,

but also of a possible and yet un-lived future.

David Whyte

2.   Embrace Spontaneity

While we organize an agenda for each meeting, we remain flexible, and when our conversations are filled with enthusiasm and creativity, we do not interrupt the excitement. We trust that the energy and wisdom of the group will provide direction. Feelings of vulnerability may arise when “thinking out loud" and straying from a planned agenda. Yet, in these spontaneous moments, previously unseen insights often emerge, inspiring continued enthusiasm.

We often smile when we think back to the moment when we recognized that the hospital system and insurance company executives, pharmacists, physicians, legislators and medical societies in our group all agree that prior authorization reform is imperative. Discovering this unexpected common ground was a good reminder that many of the assumptions that contributed to the contentiousness of our first meeting were inaccurate, and has motivated us to work to transcend our biases and view ourselves, our community and our work with a wider lens.

Our approach integrates the concept of “unordered space” as described by Cynthia F. Kurtz and David J. Snowden. Kurtz and Snowden suggest that facts and patterns emerge from the experience rather than a well-defined framework. They propose that in unordered space, knowledge arises from dynamic relationships in the moment and is a function of trust, stories, and connections.

Many participants share that they enjoy the freedom of this organic, non-linear approach, and are surprised and inspired by all that we accomplish when working together in this way. We find that with practice, it becomes easier to trust ourselves, each other and the creative process.

3.  Reach Out to “Unlikely” Friends

Colleagues often ask us “How did you convince that person to meet for coffee or come speak at your retreat?” Our response is “We just asked!” Importantly, we do not reach out to people to convince them to support or join our efforts. We invite them to meet with us to get to know them, to share ideas and insights with each other, as we would with a new acquaintance, a potential new friend.

We ask questions like “What do you feel are the most important issues that we are facing right now?” and “What do you think are the best ways to address them?” We explore our work with them, sincerely asking for their input, and similarly, invite them to share their work with us. We spend much of our time together learning about each other.

When we connect with authenticity and genuine respect, and envision new possibilities for healing in our world, the ripples generated are many and varied. Even if we do not work together in the traditional way, hopefully, we both come away from the conversation with novel ideas, inspiration and a new friend.

In a presentation many years ago, John Paul Lederach shared that in his experience, if we hope to achieve sustainable social change, “first and foremost, we must be friends."

Our Invitation:

By sharing our experience, we hope to inspire people to join us or develop their own Physician Well-Being Action Collaboratives so more people can come together in community, and with kindness and genuine respect for each other, work to enhance the well-being of the physicians who dedicate their lives to care for us.

Generating system-level change may feel overwhelming, or perhaps even beyond reach, yet our experiences have taught us that when friendship is the heart of our work together, substantial social and cultural transformation and healing are possible.

Social healing is made up of space moments of resonance,

voices touching voices in a common space.

John Paul Lederach

Dr. Deb Roman and Dr. Ed McEachern founded and facilitate the Idaho Physician Well-Being Action Collaborative (IPWAC) and work together on the board of the Compassionate Communities Healthcare Movement (CCHM). They share presentations and workshops on the transformative potential of friendship-centered community circles. Please feel free to connect with them at drdebroman@finding-health.com or edward.mceachern@gmail.com.

References:

The Pocket Guide for Facing Down a Civil War: Surprising ideas from everyday people who shifted the cycles of violence. John Paul Lederach

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Shanafelt, West, Dyrbye, Trockel, Tutty, Wang, Carlasare, Sinsky 

The new dynamics of strategy: Sense-making in a complex-complicated world. Cynthia F. Kurtz and David J. Snowden

The Moral Imagination: The Art and Soul of Building Peace. John Paul Lederach

Building Peace: Sustainable Reconciliation in Divided Societies. John Paul Lederach

Hiding

I didn’t know I was hiding.  Long ago, I was given a script. I memorized the details and performed them with flawless accuracy.  My role: woman physician.  Aspects of my personality that did not align with the script were packed away deep inside where they would not be seen.  Over the years, I diligently fine tuned the dimensions of my character, adjusting my appearance and tempering my responses to meet cultural expectations.

In time, an uneasiness stirred inside me, and as I shared my feelings with other women physicians, I realized I had become so accustomed to playing a role, I was no longer sure how to be myself.

I began to explore the possibility of breaking role. I knew I would likely be judged. I also realized I might be excluded or even attacked.  In some ways, hiding seemed so much easier. But eventually, as Anais Nin says so beautifully, “the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom.”

The judgment, exclusion and attacks became part of my experience, but the freedom of being myself, without apology, was deeply nourishing, felt important for the world, and motivated me to move forward.  Yet, without a circle of women physician friends who shared and understood my experience, I do not know if I could have found my way.  We encouraged each other to come out of hiding, explore and honor our strengths and allow our intuition and compassion to guide us.

Recently, I met a physician friend for tea. In addition to her clinical work, she works as an executive at a major hospital system.  She shared that during her annual performance appraisal, she was commended for approaching situations with curiosity.  Yet, rather than simply accepting the compliment, she told the male physician colleague who was evaluating her progress that she had learned long ago that communicating in this way was necessary if she hoped to be accepted into the medical community.  Her colleague was visibly surprised by her response.  She explained that in her experience, a woman physician who queries “I wonder…” is often received much differently than one who is too direct, and states “I think… ."

Interestingly, while my friend initially expressed curiosity to avoid criticism and seek approval, she eventually made a conscious choice to continue to communicate in this way.  She told me that did not make this decision to subscribe to the cultural norm; instead, she continued to greet situations with curiosity because she wanted to welcome different perspectives, consider new possibilities and prioritize relationships. She chose to move forward in her own way.

Many women physicians share similar stories, and are coming together in community to explore ways to navigate the landscape of medicine with authenticity.  Resisting the pressures of cultural norms is complicated and can be challenging. Yet, imagine the beautiful possibilities if we each choose to show up unapologetically, as ourselves, and bring our unique gifts to our work and the world.

The Practice of Wisdom

A few months ago, I received this text from my dad and have found the words inspiring:

Thought you might be interested in a David Brooks article today in the New York Times on the definition of wisdom. Over the ages, people tended to define wisdom as superior knowledge, but Brooks suggests that in his experience wisdom is less an impressive body of knowledge and more a way of relating to and influencing others.

Wise people usually do not tell a person what to do. They know that people only change after they feel understood and the really good confidant, those we go to for wisdom, first brings a "quality of attention" to your story, accepts it, learns how you deal with difficulties, and only then provides a non-threatening nudge to help you consider changes to your actions or relationships. It is the skillful process of walking people to their own conclusions that may constitute wisdom.

In our ideological age, where we are led to identify ourselves in categories -- male/female, black/white, liberal/conservative etc., perhaps wisdom can be seen as the way we interact with people of different opinions, not as types but as more nuanced individuals trying to understand opposing points of view and new ideas for narrowing our differences.

My dad and mentor, Jerry Sheinbach

Loosening My GRIP on Control

Sheltered at home for several months in 2020, I spent much of my day integrating a tele-health practice, exploring evolving research with peers nationwide and searching through the daily barrage of information to find answers - how does this virus work, how do we mitigate the impact on the lungs, how do we keep our community safe as we identify treatments?

Even once I returned to my office, masked and socially distanced from my patients, clear answers were not available.  We were still learning, and while we had gained valuable insights, we did not have enough understanding to prevent the devastating consequences of this disease. 

My uncle was awake and talking upon arrival to the ER.  Yet, within 24 hours, his ability to oxygenate plummeted and he was transferred to the COVID ICU and connected to a ventilator.  Motionless except for the artificial inhalation and exhalation mediated by a machine, pressor medications were prescribed to help him circulate blood to his vital organs. 

Physicians and nurses did all they could to keep his body functioning while searching for effective ways to treat this novel infection. Without a clear understanding of the pathophysiology of the virus or proven treatments, the virus was free to attack his body unimpeded.

Lack of control is sobering - compelling me to sit with feelings of uncertainty and helplessness and respect their power.

The patients I have been privileged to work with over the years have often provided me with insights.  People who awoke one day to a new reality, a life threatening illnesses that challenged everything they held dear.  

I recall the day Yvonne came in to the office. Convinced that her headaches were due to chronic sinus infections or stress, she looked at me incredulously when as gently as possible, I informed her that her brain scan was abnormal, likely identifying a tumor. 

Twenty years later, I still remember the feelings of that day.  As we talked, the air in the room felt heavy and the lights seemed to darken.  This patient who I had known for many years, who had sent me gifts when my children were born and remembered their birthdays, seemed to pull away, occasionally glancing up at me as if to say:  “do something … make this different… say something else.” 

But I couldn’t make it different - and in that moment, my body ached, my breathing quickened and I experienced a profound feeling of helplessness.

Yet, in the days that followed, in small ways, we learned together how to navigate this new normal - a world inclusive of a brain tumor - a world filled with unknowns, immense challenges and pain, and paradoxically, opportunities and blessings.

We became familiar with the unexpected and unwelcome.  We confronted our perceptions of helplessness by strengthening our connections with each other. 

The medical professionals caring for my uncle similarly endeavored to develop meaningful connections with him and with our family. They joined us as we navigated our unprecedented new normal. 

My uncle lived for 28 days on a ventilator, enduring severe secondary infections, two gastrointestinal bleeds, kidney and liver dysfunction and a myriad of other serious complications.  The physicians and nurses compassionately shared what they knew -  and acknowledged what was still unclear.  We walked together into the unknown.

In an unexpected turn of events, my uncle recovered.  The day that the endotracheal tube was removed, the healthcare team that had worked so hard to provide him with the best available care despite limited scientific data, cheered him on, cried with us and expressed gratitude for this unlikely outcome.

At times in our lives when we do not have answers, our relationships provide us with the strength to weather inconceivable storms.   They help us make room for both the tragedies and the gifts, and recognize the ever-present opportunities for compassion and connection.

My Uncle Harold - 6 weeks after discharge from the hospital.

He celebrated his 88th birthday with his family.

Superheros

A few years ago, two young patients came to visit me for osteopathic medical care.  These two children, ages 7 and 10 at the time, spent 15 minutes describing to me in intricate detail the “superhero abilities” that they would like to acquire. It was an amazing conversation.  I was so impressed with the level of detail - the physics behind their supersonic suits, the array of colors on their garments, the composition and purpose of their accessories, the ways they both felt they could save the world.

A true hero isn’t measured by the size of his strength, 

but by the size of his heart.

– Zeus

I so enjoyed listening, but eventually, they asked the dreaded question:  “Dr. Deb, what superhero ability do you want to have?” 

I say dreaded because when you are 7 and 10, these answers are clear and uncomplicated.  If someone asks you “What is your favorite color?” - without hesitation, you answer blue!  But as we get older and tend to evaluate our answers through a filter of emotions, expectations and judgments, it becomes more complicated.  Well, I like blue, but purple is also nice - and sometimes, I really like green.

I thought for a few moments, and tried to allow myself the freedom to imagine as I did when I was a young child.  After a minute or two, I somewhat hesitantly shared my answer with them.  

“If I could be a superhero and have a special ability,” I told them, “I would like to reflect to everyone I meet their inherent value and beauty.”  

Surprisingly, they shook their heads as if to let me know that this was an acceptable answer - but before I could relax for too long, they quickly shifted gears and asked  “So what will you wear?”

I didn’t have an answer at the time, so they gave me several creative suggestions, and I told them that I would have to get back to them on the costume.  

A few years later, when I was visiting the Ann Frank memorial in Boise with my friend Amy and sharing this story, she provided the answer:    “You would wear a mirror.”

This story is dedicated to Spirit “Superdog” Roman.  I am so grateful his beautiful heart and always unconditional love.  (2003-2020)

A true Superhero - Spirit flew through the foothills without wings - simply pure joy.