When you get down to the root of it all, some simple truisms seem to exist in our culture. We are led to believe that there is one path to success. We are led to believe there is always better, usually on the other side of the fence. And worst of all, we are led to believe we are never enough.

We all experience ups and downs in life. Nobody is immune, but many refuse to embrace the peace contained within this elemental truth. Our experiences serve as signposts on the highway of life. A sub-par performance or a low exam grade isn’t a reflection of your implicit value, and it isn’t a failure. As Abraham Lincoln once said, there is no failure - only opportunity. These moments are just an opportunity to measure where you are in reference to where you are going.

But there’s one thing that is often forgotten: you’re the driver. Stephen Covey once called it “response-ability” - the ability to respond to those ups and downs. Don’t try so hard to avoid the bumps that you run off the road completely. Don’t spend all your time looking in the rearview mirror when there is a road immediately ahead of you. If there is something obstructing your path, don’t swerve - ease off and redirect. It might just require pulling off to the side of the road to reflect for a moment. Or two.

Above all else … You. Are. Enough.

You are unique - so there is only one person qualified to define your success: you. You drive your own car, you set your own path, you measure yourself. Nobody can walk in your shoes, and nobody has your unique skills. Putting religious and philosophical themes aside, there is but one judge in the grand scheme of reality. Ourselves.

Sadly, many of us won’t truly embrace this until we have some life experience behind us when we have been down the road a few miles. We don’t truly give ourselves the grace to be the one that defines our success. When we’re closer to the end than the beginning, we may be less compelled to allow the judgments of others to define our success. When time is limited, we embrace what time really means to us.

If only we knew early in life that we are the only ones who can truly define our own success, we’d all be much happier. More importantly, we’d all enjoy the drive, the wind in our hair, and be present in the moment.

My life, decisions, benchmarks, journey, definition of success … and ultimately, drive.

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Ask any clinician, and they will proclaim that they are entitled to fair reimbursement for services rendered. Worse yet, they will brazenly report that they are a degreed professional, so they should “rightfully” make a certain amount of money for their care. The false equivalence, however, is that time spent with the patient, the number of interventions performed on the patient, or both has a direct relationship with the value of the service provided. Medicare further promotes this mentality by paying based on time intervals and the type of intervention provided.

I’ve heard clinicians charging exorbitant hourly fees because they feel that this is their value - or that the market will stand it - or both. I once had a prospective patient contact me. They said they had been to a physical therapist before me, who charged them $200 a visit, and had attended three visits. In Austin, that could very well be what the market will bear. My final question - before scheduling the patient - was this: what was the outcome of that experience? The response? I spent $600 and wasn’t any better.

I scheduled her initial assessment. I provided a projected time frame, a pathway toward self-management, clear expectations, and a projected outcome. I saw her for a total of three visits, at which point she had returned to full pain-free function - and at half the cost and untold increase in value.

If we are adamant about “patient-centered care” (a phrase that has become the trendiest buzzword in medicine), then how does “value” not enter into the equation? Are we asking the patient what value the care provides to them?

Now, I do understand that “value” and “outcome” are challenging terms to define. How dare I demand that a clinician provide an outcome? But here’s the problem - and the reality: health care is the only field in which you don’t have to provide one yet still get paid for services rendered. If I take my Honda to a mechanic, I agree to a diagnosis, an intervention, and an outcome. If I don’t get that outcome in the time specified, or there are issues with the outcome, then I demand that it is remedied - because I was told I’d get an outcome, and I paid for it.

Not so in health care.

I think that it is imperative for healthcare providers to ask whose value is at stake. Just because you’re a degreed professional doesn’t mean you provide value to the patient. And let’s face the music - if we keep tapping the system as we’ve done for decades, there will come a time when the system won’t continue to pay as it has. Healthcare providers have already witnessed an ongoing onslaught on Medicare reimbursement. But the flip side is this: why pay for non-evidence-based or non-outcome-driven or non-patient-centered-value-driven care? We need new models of delivery. We need accountability. We need to actively involve the patient in the establishment of value- and performance-based practices that align with evidence-based ones.

The patient defines the value - and we should all be doing our best to deliver it within a value-driven context.

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In effect, we spend our lives preparing for now. Nothing more, and nothing less. The moment right here, right now. Sure, there are some guard rails alongside the road of life. Sometimes, there is a median or dividing line, perhaps even a speed limit or two. And what brings us to today is what we’ve learned and experienced along the way. Our internal story is who we are - and we are our narrative. At any given moment, we do our best with what we have to work with. Sometimes, that’s enough, and sometimes it isn’t, but time moves on without us.

In youth, we seek guidance. We think we know that which we do not know in the name of pride and growth and security. We struggle. We fall. Hopefully, we pick ourselves up time and again. Identity finds us, at some point, on a journey of putting the pieces together and hopefully making sense of it all. If we are lucky, we learn about life, love, and the pursuit of happiness, and we look at the stars above and gaze in wonderment like children. We continue to refine the lens through which we look. As we age, we may become cynical. Or jaded. We’ve loved - and we’ve lost. But time rolls on.

In life, we are provided with opportunity.

We’re given the opportunity to learn.

We’re given the opportunity to choose.

We’re given the opportunity to accept and to let go in the most difficult of times.

We’re given the opportunity to take the bull by the horns and fight like hell.

But you never really know where you are in that process because no reference point matters other than ourselves. Sure, we always have external references, but in reality, all they do is drain us of the energy and purity and freedoms that our rightfully self-referential existence provides us. Those admired traits are also the same ones that can provide us with the greatest challenge. That can be our superpower and our downfall, all at the same time, a virtual coin toss that takes place on a daily basis.

As the line in the Doors song goes, nobody gets out of here alive. Death defines life, giving it a tangible endpoint in space and time. But the lives of our loved ones transcend time, memories tucked away in our back pockets to pull out for sunshine, joy, and happiness, melting the cynicism and angst, and making it all right even for a moment. Or two.

In death, as in life, the truisms are basic.

All I can hope for is to be the best me that I can be.

All I can hope for is to leave the world a better place than when I arrived.

All I can hope for is to leave with peace and dignity.

All I can hope for is to leave the world full of adjectives and superlatives that describe my legacy and meaning to those we love and our greater community at large - and to ourselves.

Maybe all I can hope for, all that any of us can hope for … is one big mic drop as we walk off the stage for the final time to the applause of friends, family, and the cycle of life as it rolls on without us. A life lived on our own terms, a journey of our own doing, a work of art that might look a little like Crayola or Leonardo, and the peace of knowing that we did what we could with the time we had on the planet surrounded by the people that made it all worthwhile.

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“Know thy enemy and know yourself; in a hundred battles, you will never be defeated.”

First, we will all find ourselves in a hundred battles of many shapes, sizes, and forms. They call it “life”. It might be work, family, or the daily internal struggles we may face in a world telling us we’re not good enough, smart enough, or just … enough.

However, the reality is that you must know the enemy in any battle. The skill is to know when to push forward against the enemy and when to retreat. The greatest challenge, however, is to acknowledge where the true enemy is.

I would suggest that, more often than not, the enemy is within.

We all have what Stephen Covey once called “response-ability” - the ability to respond. But those responses are often counter-productive. We become defensive. Or afraid. Or threatened. Our self-image rears its head in our preconceived notions and expectations. Our internal programming bubbles to the surface. Worse yet, if you’ve been raised in North America, you were probably socialized to believe that harder work is just what strong, tough people do - or that you should take a stance and defend it with all your might.

Pushing does not always get us closer to vanquishing the enemy. It rarely does. The enemy may not be a force to work against. Knowing thy enemy may require an understanding of what lies within. It may feel almost against the grain to slow down, step back, or let go, but it may be the one thing we need to do in the moment.

Let it percolate, as I always say.

That’s not saying that we shouldn’t forge ahead. There are lessons that can be learned when we are doing so. Sometimes, we have to just grind it out. However, sometimes, the fastest and most effective way forward is to stop. In my experience, most life events and challenges seem to have an organic life span - often unrelated to my self-imposed or perceived resolution timeline. Build your ability to respond by pausing, reflecting, and learning - whether you’re seeking results grounded in life, love, or the pursuit of happiness.

Take the time to know yourself. Be present in the moment. Let go. Breathe. Look within. Most importantly, let that knowledge lead you to all that is beautiful and fulfilling in 2024.

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Life provides us with a lot of practical horse examples. Students can be provided with all the best guidance on how to succeed in coursework. Oftentimes, they refuse to heed the warnings, making choices for a variety of reasons that ultimately may not bode well. The same phenomenon exists with patients - who may refuse to listen to our guidance regardless of our years (or decades) of clinical experience. And of course, it goes without saying that we hope that family members, be they our parents or our siblings, would act upon the guidance of their trained professional children, right?

The common theme is two-fold. First, horses all make decisions based on their own internal mental representations. These representations are inclusive of prior experiences, self-efficacy, and self-perception. Second, when those decisions are made by the horse, we have to hope that those decisions don’t generate any significant ramifications that we may have projected would happen in the first place.

When you’re invested in the outcome, sincerely wanting to support, guide, and put your best foot forward, it can feel uncomfortable leading that horse to water and then being forced to watch them remain thirsty. But what I’ve learned is that there are several important aspects to keep in mind:

1. Respect autonomy. I respect that you have the right to make your own decisions. I may disagree with you, but I respect your autonomy.

2. We can agree to disagree. I can respect your autonomy to make the decision, but I don’t have to agree with your rationale or behaviors.

3. You can’t, nor should, own someone else’s “stuff.” It’s your decision, so own it. I can’t and won’t feel badly about myself, given your choice of decisions for you. Your choice, your ramifications.

4. Set healthy boundaries. I get to define what is acceptable to me to set healthy boundaries. For example, if you choose to do nothing, you don’t get to rant to me about how you feel about having done nothing.

5. Let go. The most difficult thing that is asked of us, and perhaps the most important factor in our well-being, is letting go. Breathe. You’ve done what you can do and acted with good intent, love, and compassion. All you’ve done is attempt to be the best version of yourself that you can be … with the hope of the best outcome for all.

It’s never easy. I will admit that this is a work in progress for many, myself included. Timing is everything. Sometimes, it’s not the best time for the horse to drink. Sometimes, there is a period of reflection required before drinking. When you’re ready, I am ready. Just let me know.

And sometimes, we need to acknowledge that our internal angst in leading that horse to water is, in fact, our own angst - and with that comes a choice to let it go, yet another opportunity to learn about ourselves in our daily journey called life.

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The recurrent theme coursing its way through my existence is summarized in a 12th-century metaphor: You can lead a horse to water, but you can’t make it drink.

You can provide all the best guidance or wisdom or knowledge or expertise to that horse. It could be a family member, a student, a peer, or a patient. You put your best foot forward to give them the best of you, the best you have to offer. Why? Simple - because you care for their well-being, and you care for their success.

But the harsh reality is that all the best guidance in the world might never get that horse to drink. The horse might be thirsty, dehydrated, or need food and drink. However, they still won’t drink. That same family member, student, peer, or patient might refuse all efforts … and sometimes you, the self-appointed horse leader, just can’t understand it.

Here’s the problem - it all makes sense to the horse, not you. As the horse, they are going to do what they are going to do for whatever reasons they are going to do them, given the narrative that they’ve constructed for themselves. They draw upon their cognitive structure, experiences, and self-image. They will do whatever they can, more often than not, to remain within their comfort zones. They will operate from their System 1 thinking - fast, reflexive, experiential, and driven by intuition more than logic. And when they are led to water - what appears to be an obvious and perhaps even readily available solution to the thirst - they will push back. Hard. They will refuse to drink.

It is the refusal to drink that is difficult to watch and even more difficult to experience as the horse leader. Sometimes solutions are hard to find, sometimes they require more resources or expertise, and sometimes they are right before us. But we find them. It is the rejection of these solutions that proves challenging to the ever-supportive horse leader.

The horse will do whatever the horse will do, regardless of how we lead it, where we lead it, or even why we choose to lead it. In effect, it’s not a reflection of the horse leader, their love or compassion, or a plethora of solutions. It’s a reflection of the horse itself.

And you know what? Just that one simple realization is a big step towards internal peace and understanding.

The theme presented itself, and I heard it loud and clear. But now what? I’ll expand on some thoughts in Part II.

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I am a self-professed chronic asker of “why,” a skill I’ve refined over the years. I started off as the kid who asked it all the time. Sometimes, my efforts were applauded, but sometimes, it got me into trouble. In retrospect, if one word has been the bane of my existence over the years, for good and for bad, it would have to be “why.” But why is that? Ooops I did it again … see what I did there?

Context, as always, is important.

I have always seen “why” having a role as a force for good and not evil. There is clear and implicit value in asking “why.” Plain and simple, it serves as the basis for better understanding an issue. When I ask “why,” more often than not, it isn’t to incite debate - far from it. The only way I can truly understand how you got to where or who you are or your thought process along the way may be to simply ask “why”. The reality is that I don’t have the liberty to walk a mile in your shoes, but I might want to understand what those shoes feel like to you. Share the experience with me as best you can so that I can understand or, at worst, simply empathize. I want to understand it - to understand you.

As Leonardo da Vinci noted, “The noblest pleasure is the joy of understanding.” I would agree wholeheartedly.

I may also ask “why” to get at the root of a problem. Proponents of root cause analysis would say that if you ask “why” five times, you’ll get to the underlying problem that drives the issue in front of you. I am always amazed at how effective this strategy can be, even if the answer it generates is one that I might rather not acknowledge at the time. What I do with the understanding generated by the five “whys” is another topic.

However, like everything else, there are two sides to the “why” coin. It can get a little tricky at times. The question “why” can trigger all sorts of emotional responses. Suddenly, three simple letters are felt to challenge authority and trigger defensive behaviors that might be driven by self-image, guilt, power, self-validation, or vulnerability. You see, many people don’t want to be asked that question for a plethora of reasons - and that can make “why” a big problem.

The good intentions of asking “why” often don’t come across as we’d like. You may have wanted to establish the basis for discourse, but that wasn’t what you got. The root of “why” allows us to keep learning and embrace the diverse life experiences of those around us. In the end, keep asking - we owe it to ourselves and those around us.

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My journey began in Brockville, Ontario - population 20,000. I would consider Brockville as representative of small-town Canada, surrounded by even smaller-town Canada. It was home for the formative years of the journey that embraced kindergarten, elementary, and high school. Several friendships from that era remain with me 50+ years later. Yes, I’m talking to you, Richard, Ian, and Ed.

I spent my university years in Kingston, Ontario - population 60,000 at the time, though the greater “metropolitan” area is now listed as over 130,000. Kingston is a typical college town. However, any graduate of Queen’s University would not likely not consider their experiences at Queen’s “typical” for university (but I digress).

My most recent home has been Austin … population 450,000 when I arrived, now pushing 1 million just 33 years later. Austin was a funky and otherworldly mix of musicians, slackers, legislators, and the University of Texas when I arrived. Live music was thriving, and Austin had more than its share of epic hole-in-the-wall venues (Liberty Lunch, how I miss thee). About a decade ago, it became cool to live here. Now, half of the state of California has moved here. How do I know, other than the license plates? If you call Mopac “the 1,” you’ve given yourself away, license plates or not.

I’ve had three places I have called home, each with a different vibe, people, and lifestyles. A trip home, any of them, in fact, always puts life into a new perspective. I now find myself attending to different details about each locale. It could be the food, the way the sun comes through the clouds, or the drive past a school or institution. There is a new-found sense of comfort, of enjoyment, and gratitude. I have come to cherish the memory of experiences I didn’t realize were so important. However, I now have the wisdom to assess them through a different life lens.

The journey itself is what gives us this life lens. The journey transcends all of them. I just manifested that journey in three rather unique locales, given whatever aspect of me was undergoing transformation at that time in the grand journey. While home serves as a reminder of what was, what is, and what can be, the journey - of self-discovery, growth, and transformation - is truly my home, our home.

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Much of this comes down to an inherent perceptual flaw, I think, of why we are on the planet. We quantify our existence and base our value on material things and how that compares us to others. We are socialized to believe that we must have x, y, and z to be considered “successful”. We are never enough, but we always think we will be as soon as we have this or that. The problem festers into an ongoing and toxic comparison to others by using a reference point that isn’t relevant.

Are there times when a comparison to others is implicit to the task? Sure. We see it all the time in sports. But that doesn’t equate to your value in being you. Finishing second might mean that you have more work to do, and not that you are not good enough to do the work or are just not good enough, period. Are there times when we are wrong? Sure. However, the fear of being wrong is overwhelming to some. Being wrong might mean that you have more to learn. Both scenarios signify that in this moment, on this measure, you are not as skilled as you aspire to be. The task at hand is to learn from the experience. The beauty of life is in owning who we are and aspiring to be better.

I’ve seen the struggle with patients, with colleagues, with students, and within myself. I am the first to say that I want to be the best version of me. I am the only person that is me and the only person that can be me, so I need to use my reference points to establish what a good version of “me” looks like. I am the one that defines what success looks like - to me. It’s my path, I get to define my journey. However, I also need to live with some grace - I can’t always be that version of me, and in not doing so, I am not failing, I am just on a journey that has its good days and its bad days.

Many of these truisms have their roots in the words of the great Stoic philosophers like Marcus Aurelius and Epictetus. They were talking about this stuff long before it appeared in a self-help book or a TED Talk … circa 150 AD, a mere 1873 years ago.

“Our life is what our thoughts make it.” (Marcus Aurelius)

“He who lives in harmony with himself lives in harmony with the universe.” (Marcus Aurelius)

“There is only one way to happiness, and that is to cease worrying about things which are beyond the power of our will.” (Epictetus)

“No man is free who is not master of himself.” (Epictetus)

I wish I’d known these things earlier in life. I wish I’d truly understood what reference points were relevant and which weren’t. And I wish I knew, had been taught, or both, that we all have a superpower - and it is within us. Don’t forget that your superpower is that you are you - and you, dear reader, are unique.

Just. Do. You.

Be strong in your convictions. Define what success looks like - to you. Learn from the journey. Amazingly enough, everything will work out just fine, and the people around you will be ecstatic that you did. And those that don’t, well, they don’t matter anyway.

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The educational system got involved. It demanded linearity, forcing them into a world of outlines and if-then statements. Suddenly there was the laundry list of “what you need to know and how you need to know it” so that you can make your way through standardized tests A, B, and C. Don’t color outside the lines. In fact, stop coloring - it has served its role already. Don’t even consider thinking about your own thinking; meaning isn’t important. This isn’t the time or place for that sort of thing.

As the arc of life-long learning was developing, linear thinking was demanded of non-linear brains. But we forgot something important - that active learning requires creativity. Hanke (2012) noted that generative learning is “the process of constructing meaning through generating relationships and associations between stimuli and existing knowledge, beliefs, and experiences”. Generative learning involves creating something that makes sense to you based on your experiences and prior knowledge. It doesn’t happen through osmosis.

If there is a failure in academia, in my humble opinion, it is in failing to promote creativity in the learning process. I don’t think it is a coincidence that Leonardo da Vinci was simultaneously an acclaimed artist, thinker, and inventor. There’s a reason why “creativity” is considered to be one of the four core 21st-century skills (which also include communication, collaboration, and critical thinking - but more on that in an upcoming post).

However, when I suddenly ask a graduate student to create - after years of being exposed to other things - they look at me like I am crazy. They rebel. They resist. Of course, they are incredibly uncomfortable because that’s not what “higher education” has conditioned them to do.

Students need to generate and create their learning using those same core skills that have oftentimes been left to gather dust. They must connect the dots - literally and figuratively - using that same healthy dose of creativity that naturally came to them during their younger days. The basic elements of generative learning are rooted in kindergarten. Creativity involves making sense of what lies before you to establish meaning in your mind. As much as an instructor can guide, mentor, and provide feedback, they simply can’t make you learn.

The arc of life-long learning is ever-changing. We are all students - forever. The beauty is that you had some of the foundational elements of life-long learning long before you ever started your formal education. Create. It will serve you well and provide you with one of the most critical skills as a global citizen in the 21st century and beyond.

References:
Hanke, U. (2012). Generative learning. In: Seel, N.M. (eds) Encyclopedia of the Sciences of Learning. Springer, Boston, MA. https://doi.org/10.1007/978-1-4419-1428-6_171

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