Throughout my practice of office medicine, I have always tried to make a habit of being transparent. One of the ways I manifest this is by generally permitting patients in the exam room to view the computer screen while I am typing their information. I’ll always remember the time within my first year at the primary care office when I was seeing a rather well educated middle-aged man with a bit of hypertension. He was on medication for it, his blood pressure wasn’t quite perfect, and I suggested that we go up on the dose of his pill. He wasn’t interested in this; he wanted to try diet and exercise first. I typed: “Patient refuses to increase lisinopril and wishes to try lifestyle measures first.”
I turned back toward him to start on a different topic, but he interrupted me, saying: “That’s not what I said.”
“Pardon me?” I hadn’t even asked him a new question yet.
“You wrote that I refused to increase the lisinopril. I didn’t refuse.” He wasn’t upset, he just wanted to be quoted accurately. I gave him a conciliatory nod and changed the documentation to say: “Patient wishes to try lifestyle measures before considering an increase in medication.”
This taught me an interesting lesson. It’s interesting because I think for many doctors out there, the lesson would be to stop letting patients see the computer screen while they document! While this may help efficiency, what I truly learned from that moment was the importance of precision in language – in other words, say what you mean, and say it clearly. I think what I had written was a reasonable, loose interpretation of what he said. However, it could also be interpreted a different way, perhaps to his detriment in that someone who reads it might assume he is a difficult or argumentative patient, which was not the case at all.
I have never forgotten that, and I have taken pains ever since to use terms that describe things most precisely, whatever the circumstances of my communication. In some situations this can take more mental effort, so it is a step we often skip as physicians writing notes because we simply lack the time. And while I think we often figure it’s no big deal, being accurate in our records can mean the difference between life and death if it involves a zero here, or a decimal point there. In looser matters of language, as in the illustration above, it can actually influence how a patient is viewed and therefore treated by future providers. So there is value to saying things clearly and objectively — unemotionally, nonjudgmentally — and it may involve choosing words more carefully.
I went through all of that to convince you that there is merit to breaking down the word “can’t”, and I don’t think it’s at all as simple as trying to get people to replace it with “can.” As I described in my previous post (“The Conundrum of Can’t – Part 1”), this one little 4-letter word holds so much more meaning than meets the eye. Far more than just describing a lack of ability to complete a task, it implies failure, which triggers feelings of disappointment, apprehension, perhaps even repulsion, and these feelings drain the “sayer” of any motivation to repeat an action, let alone try harder.
I would like to propose that anytime we use the word “can’t”, we evaluate what we mean from three precise angles: 1) Motivation, 2) Approach, and 3) Result. This can help drill down whether or not we truly “can’t” accomplish something, or even decide whether or not we even should.
Whatever it is you think you can’t do, your Number One question should be: Why does it matter whether or not I do this? Is it something I want to do? Is it something someone else wants me to do? Is it important? Or is it meaningless and perhaps my lack of motivation is the very thing that makes me believe I can’t?
Before I started medical school, I was absolutely positive that I could not stay awake all night to be on call, let alone every 4th night. There was not a single bone in my body that wanted to stay awake all night, at any time, ever. But it was expected of me to do the overnight calls so as to demonstrate participation in the training that would earn my M.D. I didn’t want to stay awake overnights, but I wanted my M.D. So whereas I didn’t think I could, I made it happen.
A similar situation occurs much more frequently and more powerfully with new parents. There is absolutely nothing that prepares you for the long nights, the self-sacrifice, the mystery behind unstoppable crying, the constant flow of poop and puke which come with all babies. Any young adult who heard the full description of tasks involved in parenting would probably say, “I can’t do that.” But the reward of looking into a sweet, chubby face and seeing that first smile, watching a little personality develop, realizing you somehow played a role in creating a brand-new beautiful human being… those rewards are so immense that all the things you “can’t do” seem to fade away. And next thing you know years have gone by and you discover that you did it.
Meanwhile, people will also say things like, “I can’t live like this anymore.” This is a pure description of motivation. The statement implies that one of two things must change: either the living stops — God forbid, or the circumstances (“like this”) stop. Meanwhile the most common outcome of this mentality is that none of it changes, and the person who says it can’t be done actually just continues to do exactly the same thing, on and on. In fact, the lack of motivation behind the word “can’t” continues to fuel poor circumstances which leads to more unhappiness in life, which circles back to poor motivation, and so on. But if change is truly desired, it would be far more productive to instead say, “I won’t live like this anymore.” It replaces the victim mentality with a sense of determination, which in itself generates a change from status quo.
Once it is clear how the thing that “can’t” be done is related to motivation, after deciding whether or not you really want to do the thing and exploring why or why not, the next questions are the more classical understanding of ability or accomplishment: “what” is being done (approach) and what is coming of it (result)?
The common summary of “can’t” involves an attempt and a failure: “I tried but I didn’t.” By looking at the approach, we are peering into what constitutes an “attempt,” or the act of trying. Assuming there is good motivation to accomplish a particular task, a lack of success is often due to problems with the “how.” Stepping back to re-evaluate one’s methods is a well-known way of getting from “can’t” to “can.” It may mean breaking things down into steps and slowing down the pace; it may mean practicing to attain mastery of a difficult activity like in learning a dance step or to properly swing a baseball bat; it may mean getting creative and using a completely different tact. It may mean seeking help.
But before fretting over how to change an approach to doing something, it helps to first stop and just look at what is currently being done. If something attempted is not yielding success, what exactly does the current attempt look like? How is it playing out to give the current undesirable result? Is the issue in the process, or perhaps is it in the result?
A VERY common statement that fits into this dimension of our 4-letter word-of-the-day is: “I can’t lose weight.” There is nothing black-and-white or on/off about losing weight. If weight loss is a desired goal, then it is critical to drill down very deeply into the details of what someone’s current diet, exercise and general lifestyle habits are. I can’t tell you how many times I’ve heard patients tell me that they “eat healthy” and they stand all day at work, so they can’t understand why they still have a weight problem. Then when I ask what they had for breakfast that morning, the answer is something like a bagel with cream cheese. Then comes the explanation that it isn’t their typical breakfast, they only have something like this once or twice a week. The rest of the week, they hardly eat anything, maybe just one slice of toast with a tiny bit of jam and a half cup of orange juice. Getting that little bit of information barely scratches the surface of restructuring someone’s approach to losing weight. But it is a critical starting point, because just throwing the same canned diet plan at every person who wants to lose weight will not work. Structuring a plan for an undertaking of this magnitude requires close examination of the baseline situation then defining goals, and customizing methods according to an individual’s medical history, social situation, and so on. The bottom line is that it helps to know where you’re starting before figuring out the path to the destination, defining the current methods that are going nowhere so the failed steps can be replaced with steps that are more workable and yield the desired outcome.
Developing a clear picture of that outcome is the final and obviously important piece to picking apart the idea of “can’t.” What exactly is that thing you feel you can’t do? Is it that the thing absolutely cannot be done, or is does something bad come as a result of doing it, even if the thing is technically accomplished?
Let’s look at an example from my last post: “I can’t bend over.” It is very common for someone to say when an activity results in pain that the activity can’t be done. The two most common causes of a problem like this are muscle spasms and sciatica (essentially a pinched nerve). In both of these cases it is very important to keep moving lest the problem worsen. But the moment a patient assumes that they “can’t”, they proverbially –and almost literally– shoot themselves in the foot. They restrict their activity because they fear the pain (and without a clear knowledge of what the pain means, this isn’t necessarily an illogical approach). But the immobility leads to deconditioning which only makes it harder to move with the passage of time. And the irony is that the motivation to move is pretty legitimately there. No one wants to be immobile. But because movement causes pain, there is fear that more damage is being done, and the assumption is “I can’t” – meaning, if I try, I make it worse (which is interpreted as failure). What people in this situation need is to be taught safe movement. And they need to be counseled: with careful therapeutic movement, the pain may get worse before it gets better, but if the pain is held at bay by lack of movement then it may never get better.
In situations like this, whatever little bit can be done should be done repeatedly and with skilled guidance, until “can” is achieved. Believe it or not, doing pull-ups falls into this category (also referring back to my last post, the story of “I can’t do pull-ups“). At the start of my time doing CrossFit, there was nothing even remotely resembling pull-ups that I thought I could do. But the coaches knew otherwise. If you put a tall enough box under the pull-up bar, anyone can jump off the box and pull their chin over the bar. If you get your chin above the bar, anyone can hold themselves there even if only for a few seconds then slowly lower themselves down. If you do these things repeatedly and with skilled guidance, you eventually get stronger and more proficient with these ‘partial’ goals. Then you attempt another step and become proficient at that. Then you do a pull-up. Then you do 10. Then you do 50.
My point is that reframing the desired result by breaking it down into “mini-results” is a legitimate way to achieve a task and claim an ability where there once had been inability, or disability. Success is commonly a result of the diligent pursuit of progress. One step at a time, perhaps only baby steps. But forging ahead despite the obstacles, no matter how slowly, will still get you to the finish line. Ask the tortoise who raced the hare.
We all want to be able to do what we want to be able to do. So before declaring that you can’t do something, it may be worthwhile to tease out what you actually mean when you say it.
- Ask yourself whether you really want it,
- Look carefully at how you are going about trying to do it since there may be a more skillful way (including seeking help), then
- Figure out whether the desired endpoint can be reachable by taking one step (or half-steps, or quarter-steps etc.) at a time to get there.
It may take longer than planned, but you just may surprise yourself in the end.