In Eckhart Tolle’s book The New Earth, he asks the question, “Who are we?” Are we our thinking, feelings, thoughts, and emotions, or are we something else? He suggested that we are not our thoughts, feelings, or emotions but we are the observer of those thoughts, feelings, and emotions. We are the person that can step back and look at our thinking, and that’s a big part of mindfulness and meditation. How do we step outside of our thinking and observe it, without passion or judgment, and just observe what’s going on? When we can do that, we can be more unbiased in our thinking. It’s profound how much that can change how you think on a day-to-day basis.

In Tim Ferriss’ book, Tools for Titans he interviewed all these really powerful people in business, entertainment, and the world. One of the things that 80% of them had in common was that they all practiced mindfulness. They practiced looking at their own thinking. Now when it comes to medicine, you have to constantly evaluate your thought processes, and the programs that you’re running when you take care of patients. If not, you will make mistakes. Profound thinkers often think about how they’re thinking. It’s called metacognition.

Now, I’ve talked about that in a number of videos in the past. Podcasts, blogs, YouTube videos. Today I want to give you some tools to avoid thinking that’s stinking. My hope is this newsletter opens up some channels on how you can look at patient care at a deeper level. Firstly, have a dedicated listener or a coach. Have someone that you can run things by, that can listen to you without passion or judgment, and give you feedback on your thinking. This takes a lot of courage, though. You have to be willing to dive into your motivations and biases and question them.

Are they healthy and aligned with your core values? Are you a practitioner that knows you practice fiduciary medicine, and you’re always out for the patient’s best interest? That is our ideal state. Or are you more practicing for your own convenience? More for ego inflation? Are you practicing more for money, or time-sensitive nature, or to be liked by your supervising doc, or the nursing staff? If you have bad motivation, you will have bad thinking and you’ll try to justify that. A dedicated listener allows you to avoid what Plath calls “Bell Jar Thinking.” It’s like, if you put a bell jar over your head and you talk, and talk, and talk, well, you keep breathing in your own hot air. You don’t leave room for innovation of thinking from outside sources.

Now, the second thing I would suggest is, unhealthy people cannot take care of unhealthy people. Sick people can’t take care of sick people. In Stephen Covey’s book, The 7 Habits of Highly Effective People, the 7th habit is to “Sharpen the Saw.” He tells the story of a guy who’s cutting down a tree. He’s working really hard, and he’s working and sweating. He’s very fatigued, and someone comes by and says, “What are you doing?” He goes, “Well, I’m cutting down this tree.” He says, “Well, why don’t you stop doing what you’re doing and sharpen the saw? You’ll cut better.” And the guy says, “No, I’m too busy cutting the tree down to stop and sharpen the saw.”

It’s analogous with being so busy driving that you can’t stop and get gas. It’s the same thing. You have to take care of yourself. As a clinician, you have to take care of yourself in your four quadrants. That is physical, emotional, spiritual, and mental. Stephen Covey wrote a second book that’s equally as good as the first. The 7 Habits of Highly Effective People is, I feel, a baseline book for growth. It’s one of the most influential books I’ve ever read. It’s a timeless set of principles that you can apply. It’s kind of like Dubin’s For EKGs. The 7 Habits of Highly Effective People is like the Dubin’s for personal growth.

But he also wrote a book called The 8th Habit. Equally as powerful, speaking on how to find your voice and how to inspire others to find theirs. And again, he says there are four intelligences: physical, spiritual, mental, and emotional. If you want to know how you’re embracing those intelligences, he asks these questions.

1. “If you had a heart attack today, how would you live your life differently?”
2. “If you could speak to God quarterly, how would you behave differently?”
3. “If the half-life in your career was only two years, how would you study differently, and what would you learn now?”
4. “If everything you said about another person, they could hear you, how would you speak different?”

So, those are the ways to best know if you’re embracing your intelligences. I know that in this brief body of work, there’s no way I can give you tremendous insight into practicing metacognition or practicing the art of thinking about your thinking. But again, it’s a catalyst for your thinking. With metacognition, first and foremost, you have to be dispassionate about your thinking and not embrace ego in your thought process.

When I say that, I recommend you don’t ever assign more than 90% certainty to any decision that you make in medicine. Because then you get into an ego phase. There’s always room to be wrong. So, what I say is, don’t ever assign more than 90% certainty. It’s most likely, it’s probably, and that’s the language of being open-minded. So, that’s how you avoid ego getting too invested in your diagnosis.

I also recommend mistrusting strong emotions and value judgments. If you have a patient who you really like, well, you’re not going to think about them accurately. You’re going to be more biased towards them. That’s why we never take care of family members, or we shouldn’t. If you dislike a patient too much, you put yourself in a position to not treat them right because you go in with a closed mind. You constantly have to avoid strong emotions. Or, if you’re feeling them, acknowledge them, and say, “Hey, I’m feeling strong emotions here. I better readjust my demeanor. I better recalibrate how I’m feeling right now.”

I was a Marine in Desert Storm. We were in a hot unit over in ’91 in Kuwait. We crossed the border, we were being engaged by enemy targets and we were firing back. And I was super-scared. At times, I would engage enemy targets. When they would surrender, I’d find myself very angry that they got away with surrendering, when we wanted to kill them. We wanted to annihilate the enemy. That was very deep and very personal. And guess what? The Marine Corps is very good about depersonalizing the enemy to make us efficient as Marines. Do not think for a second that I didn’t carry some of that baggage home from the war.

So, when I take care of patients that remind me of my enemy, it triggers something in me that’s not healthy. I need to acknowledge that, because I don’t want to be a practitioner who doesn’t practice excellent fiduciary medicine. That just means I have to acknowledge it. It doesn’t mean I’m a bad person, it doesn’t mean that I’m abnormal. It just means that I have some past baggage that I have to deal with, and I have to take proactive steps to make sure I don’t treat people wrong.

Now, in the book, The Checklist Manifesto, Atul Gawande talks about making lists and following lists. As often as you can, use checklists, whether it’s a literal list or a cognitive list. I teach in our emergency medicine curriculum there are five causes of chest pain. The mnemonic is, “Who’s your PAPPA?” It’s the pericarditis, acute coronary syndrome, pneumothorax, PE, or aneurysm. And I run that cognitive checklist because I know those are the five lethal causes of chest pain. So, I’m very mindful of that.

Or, if I have someone with pulmonary symptoms, the mnemonic I teach in our emergency medicine course is, “Don’t make a HORID mistake.” Is it their heart (or CHF), obstruction, reactive airway disease, infection, or death from the P, pneumothorax? Those lists are timeless, and they help me. I use that cognitive checklist often so I don’t miss anything. Know that pilots, every single time they get in an airplane, they run a checklist so they don’t forget to do something basic, because checklists work.

I would recommend developing a system of feedback and accountability. That means leaving a really open door for feedback from your supervising or collaborating physician. I find that most people do not like to give negative feedback or things that could be perceived as negative that can really affect a friendship. You have to understand that, if you are committed to patient care, it is not about you, and it’s not about your fragile ego. Therefore, you, as the clinician, should go talk to doctors and nurses that work with you and say, “What would you recommend I work on?” I would say, “If there’s anything that you think I’m not doing well, could I get feedback on that?”

And really be open and honest. There are a couple of different kinds of feedback. I mean, people can give you feedback to build themselves up, and that’s not the kind of feedback that I’m talking about here. Find someone that you love and care for, and that’s emotionally mature, that can give you feedback and show you where you’re deficient. I suggest you go talk to some people that are close to you and say, “Is there one thing you recommend that I work on, or is there something you see me doing I should change?”

Bruce Lee was a master martial artist. He taught a fighting style called Jeet Kwon Do, “the way of the intercepting fist.” He taught that a traditional martial arts style had a black strike kind of fighting pattern, where he said, “Why don’t you block and strike at the same time?” He tells the story of training this martial artist who was a black belt. The martial artist came in very closed minded and not open to learning. Every time Bruce would try to teach him something, the guy’s psychology was, “I know that. I know that. I know that.”

Then at the end of the training session, Bruce poured up some tea, and he let the tea overflow in his cup. And Bruce said to him, “You have to learn to empty your cup.” And that’s the last point I want to make in this newsletter. You have to keep room to learn. You always have to keep your mind open to taking in new content. If not, you can’t be taught anything. If you think you know everything, and if you think you’re at the terminal end of your knowledge, you’re close-minded and you won’t be open to learning.

As a clinician, as a father, as an entrepreneur, as a Christian, I love learning. I love having new insights. That’s been really transformative in my life. I belong to an entrepreneurs’ organization, where I meet with other group members who have successful businesses. We talk about business strategy in our lives. I joined this group because I really wanted to grow my business. It was not about friends.

I recently heard a TED Talk where they said the secret of happiness is relationships. That’s the subject of a Harvard study that’s been going on for 75 years. The study found that at the end of their lives, what ended up making people happiest were their relationships. It made me go, “I’m keeping a lot of people at arm’s distance because I’m more focused on my business than these relationships.” And it immediately changed my perspective and I said, “Okay, let me try to get to know these people at a deeper level, and be a better friend, and accept friendship in my life.” It’s been a really neat journey. So, I’m always open to learn and I would challenge you to do the same.

Thank you for reading this month’s newsletter.