2. Achieving Flow: My Remarks to the UVA Graduating Class of 2022

In this episode I play my remarks to the UVA Graduating Class of 2022. I share a bit of my life story and how I've learned to use ICU physiology as an approach to conceptualizing and solving problems in my life and career.

The core concept is that Flow is akin to making progress.
- Flow  depends on two variables: Pressure and Resistance.
- Mathematically, Flow is equal to Pressure / Resistance.
- Meaningful impact requires having the right amount of pressure and resistance.

 Topics
- Establishing flow as progress in life and career (01:13)
- How does flow happen? (03:00)
- How pressure works (04:37)
- How resistance works (10:07)
- The power of diversity (14:45)
- The unmeasured variable: The power of belief (17:03)

Links
- Video link and text for Dr. Bell's Commencement Speech
- Follow Dr. Bell on Twitter

Transcript

2. Achieving Flow: My Remarks to the UVA Graduating Class of 2022

Intro

[00:00:00] Hello, everyone! You are listening to This Medicine Life. I'm your host Taison Bell, a Critical Care and Infectious Disease physician at the University of Virginia. And, if you're like me, you may love being an academic medicine, but it's hard, y'all! The goal of this show is to make that just a little easier through the power of connection. We're interviewing medicine faculty, both inside and outside of UVA. Our goal is to connect with each other, to share our stories, our tips for success, and - together - become the best versions of ourselves in life and career.

Pre-Speech Segment

[00:00:37] On Sunday, May 22nd. I had the incredible experience of giving the commencement speech to the UVA class of 2022. I shared with them part of my life story and how I've come to think and visualize problems that I solve using concepts that I apply in the ICU. Namely, thinking about Flow as Progress and how flow depends on two variables: pressure and resistance. 

[00:01:04] I'm sharing here in case you can find it useful in your life in career. Let's go right to it, and I'll start with where I jumped right into the analogy. 

Speech

[00:01:13] My part of the world is in healthcare, which on the surface also seems complex.

[00:01:17] The human body has around 600 muscles, 206 bones and his blood vessels, if you arranged them in a straight line, would circle the earth two and a half times. We have hundreds of procedures at our disposal and over a thousand medications that we use to nudge the body towards a closer state of health. But on a basic level of what we do is simple, we maintain flow for our patients. 

[00:01:38] It could be the flow of air to the lungs or to flow of blood, to organs to deliver oxygen, the flow of bile from your gallbladder. Flow is what we manage in the ho spital. When flow suddenly stops, it can be a dire emergency. If the heart stops we call that a code blue and we have to work quickly to try and reestablish flow. 

[00:01:56] In a code the first few minutes are crucial and there's a lot you have to do. You can easily have up to 30 people converge in one place at one time. You have folks lined up to give chest compressions, putting pads on the chest so you can deliver a shock placing IVs, drawing up meds, delivering medications and keeping track of time.

[00:02:12] Now imagine, all of this happening in a 130 square foot room, 10 by 13. It is utter chaos. 

[00:02:21] But there's something interesting about watching these teams in action. No matter your background. I bet if I took any one of you today with me to watch these code teams, you could distinguish a high functioning team from one that wasn't. In a high functioning team the chaos eventually dies down, people fall into their roles and they help each other. Communication is seamless. People don't have to shout over each other. The team itself flows. 

[00:02:46] And just like in the rooms where I'm called to serve, in your life, you have to achieve flow. You have to make progress. And the world has to make progress.

[00:02:54] And more often than not, that progress needs to happen in an environment full of chaos. 

[00:03:00] So how does flow happen? Well, it turns out it works in life the same as it works in physiology. We're going to move to the core concepts portion of the course. So mathematically the flow between two points is equal to the pressure difference between those two points and inversely proportional to the resistance between those two points.

[00:03:18] Look, y'all I know some of y'all were out late last night. This is a lot to take in right now. So I'm going to break it down. I'm going to use a teaching aid.

[00:03:34] All right. This tube that you see was made by Melissa Goldman and the A-school fabrication lab-or the "Fab Lab."

[00:03:44] I'm going to tell you its story later, but for now, imagine the tube as a conduit for something. A blood vessel, a straw, or really anything through which something needs to move from one place to the other. It's a journey. And that journey could be as simple as air moving from one end to the other, or as complicated as working towards your life goals or impacting your community.

[00:04:05] Now that journey, or flow, depends on two variables. First is pressure that's directly proportional. That means a higher pressure on one side, means that flow will move quicker, easier to the other side. Hopefully that makes sense. Second is resistance. Resistance is indirectly proportional. When it's high, it's harder to make that progress. So imagine there's a blockage in the tube, or you imagine the circumference was smaller, narrower to higher resistance. So higher resistance, less flow. 

[00:04:36] All right. Makes sense? All right. 

[00:04:37] Let's talk about pressure first. Most of us tend to perform a little better when we're under a little pressure. And that's what I told myself before I stepped up here today.

[00:04:47] Now I know that there are some of you out there who are the kinds of folks who never procrastinate. You always complete your assignments ahead of time. You're never up late against the deadline. Just know if that's you, we see you, we smile at you. We secretly resent you. I'm sorry for that aside. It had to be said. Let's get back on track.

[00:05:11] Now. I grew up in Lynchburg, just a short distance away, but in a neighborhood that may as well have been worlds apart from UVA. During the school year, I lived with my great-grandmother and I visited my parents in the summer in Dorchester, Mass. And in third grade my teacher, Ms. Pugh, realized that I needed more pressure.

[00:05:28] She polled the class on topics that we wanted to learn about and, like a typical third grader, I wanted things like dinosaurs and outer space, but someone already wrote that. So I decided to write something different. I wrote Shakespeare and I'm pretty sure I wrote it, like "shake a spear." I was only one letter off with that, by the way.

[00:05:46] I remember hearing his name in a candy bar commercial, and I looked them up and I saw that he wrote these things called sonnets. So when Ms. Pew asked why I wanted to learn about Shakespeare, I told her, "Well I was thinking maybe we could read some of the sonnets in class. Now... 

[00:06:00] someone's laughing...

[00:06:02] I had no desire to do that back then. I continue to have no desire to do that now. But soon after, Ms. Pugh recommended that I apply to the G.O. Center, the city's elementary magnet program. It served the entire district, fourth and fifth grade. I was only one of two black boys there. And I had a new set of classmates, but I recognize their last names because they were the same last names as the doctors, lawyers, business owners, and politicians in town. So I started taking the accelerated classes, working with students for whom college was assumed rather than for me, which was a dream. 

[00:06:36] I wish I could tell you that was it. But by 11th grade, I was not on the right path and my performance was poor.

[00:06:41] My civics teacher, Ms. Frazier pulled me aside and turned up the pressure. She told me I needed to get my act together. And from then on, I was going to take advanced courses and make all A's in them. And that's actually what I did because she didn't present this as if it was optional for me. The next year, she encouraged me to apply to UVA and I was accepted with the help of her letter of recommendation and some late breaking all-A report cards..

[00:07:05] So pressure definitely benefited me. And what's interesting about this concept is that pressure for performance is also true in human physiology as well. For example, if the patient is placed on a ventilator, we have to apply a minimum level of pressure to the lungs in order to keep them open, to prevent them from collapsing.

[00:07:21] When the lungs are open, they can gather oxygen for the rest of the body. 

[00:07:25] Likewise, Ms. Pugh and Ms. Frazier opened up my future and I was able to succeed in an environment that often suffocated potential. So the lesson is if you want flow, if you want to make a difference, you sometimes need a little pressure to unlock your potential.

[00:07:42] But it's not that simple because increasing pressure is not always a good thing. 

[00:07:47] In the ICU. We know that if the lungs received too much pressure we can actually cause damage. During my third year here I had a moment where I felt the pressure was building too much. I was pre-med. I was a chemistry major and I was studying for the MCAT that's the med school prep exam. And I wasn't doing well in my biochemistry course and I went to see my professor to talk about withdrawing and he sat me down and he told me, look, I'm going to sign this withdrawal form for you and you can do whatever you want with it. But I believe in you and I know you can do this.

[00:08:18] I hope you throw it away. And have to tell you it was a good pep talk. I was inspired. I was inspired to walk even quicker to the registrar's office and withdraw from that course. It's too much pressure. I didn't need that. So I eventually dropped the Chem major altogether and chose African-American and African studies. I departed from the script I departed from the script as Dr.

[00:08:45] Claudrena Harold so eloquently described yesterday. I even took the class with her. And I found the journey that for me was much more fulfilling. Avoiding pressure overload is vital to success, but there's something that we need to talk about. Many of you are the first generations to have grown up with social media where a curated version of someone's life can be presented as if it's reality. We forget that when a light is shined on someone, there's always a shadow that's cast behind. 

[00:09:12] As a result, there's this increasing amount of pressure to be perfect and everything that we do. And when you feel like you don't measure up, it's hard to realize your value. We've seen too often, the consequences this has had on mental health and well-being. 

[00:09:26] The lungs can literally burst if they have too much pressure. The air escapes from the inside, it collects on the outside and it compresses the lung.

[00:09:35] It's an emergency. When that happens, we actually have to stick a needle or a tube into the chest to suck that air out. We have to decrease that pressure. 

[00:09:44] So the lesson is, if you want to have sustained flow, don't let the pressure get to the breaking point. Give yourself some grace. Ease up and rest when you need to. You will fail from time to time, but progress is the goal, not perfection.

[00:10:00] And, most importantly, if you need help, seek it out before it becomes a crisis. 

[00:10:07] All right, that's the pressure. So let's talk about the second variable, resistance. Remember high resistance impedes flow, lower resistance makes it easy. But as you can imagine, it's not that simple. 

[00:10:19] A common procedure in the ICU is an intubation where you place a breathing tube into the patient's throat. Right after the tube goes in you connect it to a bag that you squeeze with your hand to pump air into the lungs. We're taught that if the squeeze is too easy, you could have an air leak in the system because the lungs are elastic. They naturally resist expansion. So in other words, if you feel no resistance, you can have great flow. You can squeeze all day, but you're delivering air back into the room instead of into the patient. 

[00:10:50] And in life, you need to feel some resistance. Sure, it makes problems harder to solve. It makes them more complex, but it's also what makes them worthy of being solved. 

[00:11:02] The lesson is you can have flow if things are easy. But if you want to do good in the world and have meaningful flow, expect to meet some resistance along the way. 

[00:11:12] There was one time I intubated a patient and the opposite happened. It was incredibly hard to squeeze the bag. And so I put two hands on the bag and started to squeeze. But then after a couple of minutes, my hands started to cramp up and I couldn't squeeze anymore. So I had to pass it off to a colleague and we alternated like that until we solved the problem. So, how do you overcome these high resistance issues?

[00:11:31] Well there are two main forms of resistance. The first is from your personal professional challenges, and this is where mentorship comes in. It's vital. Mentors give you good advice and they try to lower the hurdles that you face. 

[00:11:42] During my second year of medical school, I had this big test coming up and I locked down the study, even told my family and friends I wasn't going to call.

[00:11:49] I needed to study. And the test actually went well. But when I called my grandma afterwards, I could tell that something was. She had been skipping meals and didn't tell me, because she wanted me to focus on the test. 

[00:12:03] Like many other first generation students, I had to work to support my household in high school and continued that in college. Winter was always the toughest time because the energy bills went up.

[00:12:14] The problem was I couldn't work in medical school and that winter energy prices rose 10% from the year prior. This broke my grandma's finances. And she was not the kind of person who asks for help. So she had the choice to be cold or hungry. She chose the latter. Now it wasn't comfortable talking about this with my classmates, but they noticed that I was down and I had stopped engaging.

[00:12:34] Someone, told my Dean of diversity, Dr. Hilda Hutcherson. And she called me to her office and I broke down. I told her, I didn't know if I could continue on. I just wanted to go back home. I was up against the structural forces that resist the progress for so many first generation students. And I was near ready to tap out. 

[00:12:54] Right there on the spot she wrote me a check for a thousand dollars for me to send back home. 

[00:13:01] And now not only do you know how incredible this woman is, but I've confessed to thousands of people that I owe my med school diversity Dean a thousand dollars. 

[00:13:12] I hope she's not charging interest. 

[00:13:14] The second kind of resistance takes the form of the barriers to solving society's critical problems like racial injustice, health disparities, climate change decreasing economic mobility, and the growing influence of disnformation.

[00:13:27] And when I think about these high resistance problems, I think about the heroes I studied in the classrooms behind me. People like the folks my children are named after: Professor Julian Bond, Dr. Alain Locke and Ruby Bridges. 

[00:13:40] A few days ago, I watched a commencement address by John Lewis, where he told the story of their Freedom Rides through the Deep South, how they were beaten on the bridge in Selma on Bloody Sunday in March of 1965. 

[00:13:50] He described these acts of civil disobedience as "Good Trouble."

[00:13:54] And what he meant by that is sometimes when the resistance is so high, you have no choice but to act and dial up the pressure. And I like his example because the math actually checks out. When you have fixed high resistance in order to achieve flow, you have to increase the pressure until you can ease those systemic barriers.

[00:14:15] In this case, they protested (pressure up) and they got the Voting Rights Act passed (resistance down). There are several examples of that. When it comes to COVID, we have two physicians in the community.

[00:14:28] Dr. Ebony Hilton, when you see her on TV, she's dialing up the pressure. Dr. Cameron Webb, one of my colleagues and friends, he's in the White House on faculty here, he's working to decrease resistance to implement programs that make a difference when it comes to COVID equity.

[00:14:45] But here's the thing. You can't keep this up on your own. You need people to pass the bag too like I did an ICU. And you need folks to help bring down that resistance. And when my heroes would call their experiences, they're quick to point out the people that were there with them. There's power in working with other.

[00:15:03] We can become so siloed in our careers and personal lives that sometimes the resistance, to progress is actually the lack of collaboration itself. 

[00:15:12] Now I saw the power of collaboration early in the pandemic. We were low on PPE, that's personal protective equipment. Jessica Dennome, one of our nurses, sent the email to Will Guilford in the E-School.

[00:15:22] Asking about, she asked about 3d printers and other ideas to helps solve the problem. And an initiative was formed that included folks from the hospital, the E-school, A-school and the Ed School. We need to help with logistics. So I pulled in my Darden classmates, Tiffany Pillifant and Andrew Harris, along with Rebecca Steele, a nurse in the community. 

[00:15:42] All told we produced masks, face shields, nasopharyngeal swabs, and other items that went into our local community and throughout the Commonwealth.

[00:15:49] And remember, this was before we had treatment before we had vaccines. PPE and testing, was it. That was what we had. The tube I showed you earlier is signed by several faculty and students from the project. They're from the various schools that are here today. And I have no doubt that there are people in our community, in our Commonwealth who are alive today because of what happened here.

[00:16:19] That's the power of collaboration and diversity.

[00:16:26] When people with different skillsets and points of view come together, the unimaginable can happen. And the magic about this day is you all get to go out into the world and join the UVA family as alumni for only a part of UVA's power exists right here. Most of it comes from the network. From those who sat before you and are changing the world out there. 

[00:16:51] The lesson is, when you're tackling high resistance problems, you need others on the journey with you. They can help you sustain the pressure to overcome resistance, or they can help knock down those resistance to flow. 

[00:17:03] So there it is. Flow depends on pressure and resistance. Simple, right? 

[00:17:08] Well, I hope you picked up on the theme, "It's not so simple." Because there will be times when you feel like you should have flow, but you're still stuck.

[00:17:18] There's one day I was only six years old and it snowed. How good would that be? If it snowed? I was six and the older kids came over to help this led in my backyard and I was trying to keep up and climb up this hill on my own. But each time I slid back down, I just couldn't do it. I was so frustrated. I sat down and tears at the bottom of the hill.

[00:17:40] Grandma called me inside. And I must've looked a mess. I had that thing where the tears were mixed with the snot from my nose, and it was kind of congealing into this frozen goo on my face. She sat me down and cleaned me up, gave me some hot chocolate. She had noticed that each time I tried to go up the hill, I was so focused on the top I wasn't actually looking down to see where my steps were going. She said I could stay in if I wanted to, but if I went back out, I should focus on where to take my first step. Then the next step, then the next step. I went back out and tried again. This time recalling the many times I climbed that hill in fair-weather. Remembering where some of the rocks and the divots and the roots were where I could get a foothold. And I didn't make it up on that first try, but I kept trying and I finally made it to the top.

[00:18:29] I want to close by asking you one question: what the grandma changed for me on that hill to achieve flow? She didn't add pressure. She told me I could stop and stay inside if I wanted to. She made my choice. 

[00:18:46] What about resistance? Did she make the challenge any easier? No. Same hill, same gravity. 

[00:18:54] There's a variable in this math that I haven't accounted for.

[00:18:58] So what's that?

[00:19:01] Well, I think it was the power of belief. Her belief in me made me believe in myself. I had a new strategy, but belief gave me the confidence to try again. 

[00:19:15] And reflecting back, what was it that made John Lewis get up after he was knocked down in Selma? What was it that made Ms. Pugh, Ms. Frazier and Dr. Hudson take that extra effort to help me stay on my path?

[00:19:27] What was it that kept students and faculty up all hours of the night to help a community that was in need? 

[00:19:33] It was belief. Belief in the cause for justice. Belief in your ability to change the life of a student. Believe that your skills can have an impact. That's the difference. Mr. Samson talked about the power of a positive attitude on Friday.

[00:19:51] Belief in yourself translates to your attitude, your effort, and your will. You may have to try again. You may have to try in a different way. The goal may change, but belief will make you try. It's what makes you take those next steps. It is unmeasurable. 

[00:20:11] The biggest mistake I made early in my journey was I thought I had to shoulder my burdens alone. And when I stumbled, I didn't let the belief others had in me reinforce belief in myself. 

[00:20:24] And despite my accomplishments 17 years ago when I sat where you are, I did not fully believe in myself. I felt purely lucky to be here rather than both lucky and worthy. 

[00:20:38] If that sounds like you promise me something today, you don't have to remember anything else I've said, but promise me this: work on believing in yourself today. Right here, right now. Because today you've finished this stage of your journey in the Academical Village.

[00:20:53] No matter your circumstance, you've worked hard to make it here. You've had the climb. You've overcome challenges. You did this during a pandemic. Now it's time to use your talent to do some good in the world. I'm going to put a little pressure on you to unlock your potential, but not too much, take care of yourself.

[00:21:11] I urge you to tackle the problems that are worthy, the ones that have resistance. And when that resistance is high, use the power of your mentors, your friends, and your colleagues that turn up the pressure and lower those barriers. And when you're feeling like you're stuck, or that you're not good enough, or that you're not deserving, or that you're not worthy to take on the challenges of our time, I want you to regroup, remember that you have a family, a University, and a community that believes in you, and I want you to take those next steps. 

[00:21:41] Thank you very much. And congratulations.

Outro

[00:21:54] And that's our show! Thank you for listening to This Medicine Life. If you enjoyed the show, please subscribe, write a review, and tell a friend. We are available wherever you get your podcasts. This show was created, recorded, and edited by - me. Music is by Dr. Malcolm Lex. 

[00:22:11] Views and opinions expressed to not necessarily reflect the view of the University of Virginia or any other entity. Please send me your ideas for topics you want to hear about or guests you want to have on the show. My Twitter handle is my first and last name, Taison Bell. Please stay tuned for the next episode. Until then, I'll see you around.