Knowing When -- and How -- to Push.

I've been having syncopal (fainting) and pre-syncopal (near fainting) spells over the past two years, of yet-undetermined cause. I eat well, sleep well, hydrate well, train well, recover well, and all my labs are normal, as is a CT of my brain. Cardiovascular work-up has yielded a super-common congenital defect in my heart (25% of people have a patent foramen ovale) but it's unlikely that significant deoxygenated blood would start being shunted to my brain now -- there has to be something else also going on. It's most likely a problem with my autonomic nervous system, or an intermittent cardiac arrhythmia that is preventing adequate blood flow. To figure out which, though, is a horrifically expensive and inconvenient process (as is being whisked off by ambulance to a hospital in the middle of nowhere after having one of these spells whilst driving on the Interstate).

My episodes tend not to be exertional, though my doctor and I decided it would be important to do a "stress test" anyway. Stress tests, conventionally, involve jogging on a treadmill while hooked up to electrocardiogram (ECG, or more commonly known as EKG) leads. When the technician deems that the patient is working hard enough to represent a "maximum effort" (i.e., conditions where any electrical conduction abnormalities of the heart indicative of inadequate blood flow are most likely to be observed) the test is complete. For a well-trained athlete, it is easy to appreciate where this could go awry. My metabolically measured lactate threshold is 184 beats per minute. 106% of LT (i.e., something I can sustain for an entire 30 seconds where I do my regular weekly or bimonthly anaerobic interval training) is 196 bpm. If you want to see my heart at max effort, buddy, jogging on a treadmill isn't going to cut it. I decided, therefore, to do my own stress test. On the day that I had to wear a 24-hour continuous electrocardiogram monitor (Holter monitor), I decided I was going to go to a gym and push like I've never pushed before.

The mission was a total flop. But I learned a ton about myself as an athlete, and as a coach, in the process -- so I figured I'd blog about it...

Over time, I've gotten the endurance thing down pat. I've structured my world such that the people I train either specifically come to me because they already "get" it, or I enthusiastically convert them to "get" it. I've always made it a point to familiarize myself with the modus operandi of my colleagues wherever I'm teaching, and regularly reinforce to myself the importance of serving the unique role of giving people what they're not getting elsewhere. So it has become very important to me to deliver quality, aerobic training with the physical, psychological, and emotional tools to practice it.

I've written ad nauseum about various mechanisms for "self-coaching" through aerobic and even sub-max efforts, largely centered around themes of commitment, discipline, restraint, etc. etc. etc. But I don't write much about anaerobic work. Why? I'm not comfortable with it. I very rarely take large groups above LT. While working with a smaller group where I know everyone, I feel confident in explaining:
1) why we're doing it (to train Type II "explosive" muscle fibers)
2) how we're doing it (*BAM* push to 106% of LT for 30 seconds, then recover all the way back down to 70% of LT, then *BAM* hit it again)
3) how my coaching style is about to COMPLETELY change, reminding them that they have 100% permission to ignore me at all times.

I do this every two months or so (assuming they're getting high-intensity training elsewhere) so that they learn/remember how to do it effectively (i.e., an interval of sufficient intensity/length -- NOT overshooting, lest they set themselves up for failure and disappointment -- and corresponding recovery, so that they can actually reap the benefits of this kind of training), and remember how unpleasant they're supposed to be (i.e., how "can I go take a nap now?" is not the desired outcome of most training sessions). When I do it, I'm almost exclusively off the bike, and my cues are almost uncomfortably intense. They have to be. Pushing to 106% of LT is not natural. It's not something that people "fall into," and I find it really friggin' hard to take them there.

So here I was on the elliptical trainer with my Holter monitor, tasked with taking myself there.

I began by framing my purpose. I knew that when I felt uncomfortable, perhaps downright in pain, that I'd need to remind myself of the purpose with which I began. I was doing this for answers. This may be the only chance I have to "catch" whatever is wrong. This was my last chance, wearing the Holter monitor (which, thanks to my pathetic health insurance coverage common to most medical students, was costing me close to $1000); I couldn't afford to repeat the test. And because I couldn't afford to screw anything up, I decided not to even wear my HRM (the Holter consists of EKG leads hooked up to a recorder - there is no display of heart rhythms or rates, no feedback at all). For anyone who knows me, you'll understand how big a deal it is to take this on without a HRM: I'd have no idea how hard I was pushing, no idea if I were trying hard enough.

Armed with a playlist of my "greatest hits" of tunes with 30 second power choruses, I began. Warmed up for 10 minutes to an easy perceived exertion. Then, it was time. I closed my eyes, prepared to explode at the chorus. My self-coaching began.

You need to do this. You need answers.

I pushed. I pushed as hard and as fast as I could, until my legs felt like rubber and my chest became tight. You can do this. And when I felt my legs literally liquifying beneath me, I kept with it.

End of chorus. Recover. Breathe. Looooong exhales. Heart rate (by perceived exertion) comes way down.

Next interval. Ready... ready... NOW. I pushed. 5 seconds later, my legs slowed into a comfortable, steady cadence that in NO way approximated 106% of LT, HRM or not.

First, I made excuses. If I'd had my HRM, I'd have a concrete target to shoot for -- and immediate feedback to reinforce and direct my efforts. I'd know what I can safely sustain. I could assure myself. I'd know exactly what I need to do. Without that, I can't. I just can't.

"Can't?" That's not helpful. I launched a self-intervention immediately. I tried to reason with myself, to motivate myself to do this terrible, awful thing that I had absolutely no interest in doing.

This is your last chance for answers. Nothing.

You're spending $1000, make it count! A little bit faster.

You're going to remember this. That time you promised yourself you'd push through your doubts, your fears, no matter how much it hurt. When you let this stand for something you know you'd look back on forever. *BAM*

It was just what I'd told myself so many times before. At Mile 17 of my 2nd century, in the ridiculously miserable pouring rain in the middle of nowhere with a broken spring on my front tire. At Mile 85 of the same ride, at the bottom of a 10% grade hill. At Hour 6 of this year's Ride for a Reason, after my mentor told me he didn't like my ride the hour prior and I still had to get out there and coach again. At the bedside of a comatose man last week in the hospital, as I was tasked with assessing his brain function.

And so, for the next 30 minutes, this sort of dramatic self-dialogue continued. I called up the most potent memories I could muster -- some of them proud, some of them utterly painful. Flash to a snapshot on the side of the road after my massive bike accident last year, the sound of my head hitting concrete, helmet shattered -- along with my confidence -- swearing I'd never be able to ride again. What it felt like to be so truly afraid.

I defined each push somehow to serve as coping with whatever I called up to fight against. And you know what? It worked.

If I weren't in the middle of my 6 month Spinning hiatus, I'd totally have made a ride about it.

In the end, my fake stress test was probably a bust. I have no idea if I pushed hard enough to truly tax my heart sufficient to see "anything." I have no idea if there's even anything to see.

But I did learn that the stuff I so regularly advocate in endurance coaching has JUST as much power for anaerobic efforts. Letting it stand for something, letting it mean something.

Pushing for a purpose, as a mechanism for conquering whatever needs to be conquered.

Touching Lives?

"We touch people's lives in ways we may never know."

For my first two years of medical school, I spent most of my free time at an inspiringly amazing family practice clinic in rural Vermont. The clinic's founder and director is a mind-blowingly brilliant physician who is one of the most globally impressive people I've ever met. Uniformly adored by patients, colleagues, politicians and the general public at large, every word out of his mouth is precise and utterly impactful. My interactions with him have been very carefully selected -- I've had to balance my propensity for stuttering/blabbering/otherwise embarrassing myself with how friggin' much I learn in a few minutes of conversation with him, most of which truly stays with me (assuming I have the presence of mind to "breathe my heart rate down" long enough to encode it). But the quote above, which he said to me on one of my very first days at clinic, that stayed with me for sure.

I remember being a kid and dreaming of "making a difference," "touching lives," blah blah blah, all that vague, generalized do-gooder stuff. Initially, that translated into local community service projects and general attempts not to be a jerk towards others. As I got older, I started seeking out professional opportunities to be involved with stuff that had lasting consequences, and found that I found the concept of being attached to those consequences rather rewarding. Doing stuff with consequences almost, in a sense, had a built-in feeling of purposefulness and meaning. I suppose that deciding to become a doctor is much of the same.

When I became a Spinning instructor in 2007, however, I had none such lofty ideals. I got certified purely "for the heck of it" - more curiousity than anything else; I didn't even plan to teach. When I did decide to audition to teach for a prominent nyc franchise, my expectations were quite concrete: plan training session reflective of scientific soundness --> play music that doesn't suck --> set a good example of projecting positivity and self-care --> done. I never imagined, 3 years later, that I'd have had unbelievably intense relationships through this program: people I've taught, people I've trained, people who have taught and trained me. I never thought I'd author a blog read by hundreds of people. I never thought I'd change the way I saw myself, how I saw the world. Or that, nearly exclusively through the course of my new role, that I'd carve out a way to balance my quest for "consequence" and meaning.

Simply put, I never thought I'd touch anyone. I wasn't trying to.

Yesterday, I got an email from a fellow fitness blogger who has impressed me over time with her upbeat, enthusiastic, soul-pouring posts, and with her generosity with her seemingly endless energy and creative ideas for fitness instruction. She told me a story of how something I'd written a year or so ago had inspired her to step outside her comfort zone and teach an endurance ride in a very risky setting (i.e., pressures to pack the room). To be honest, it took me a while to "register" what she was talking about. I'm on an away-rotation at a hospital in Maine, and have been so far removed from this part of my life. I haven't coached since February, haven't written for this blog (or ICI - I promise, 4 weeks til this rotation ends! My next medical column will be about use of blood pressure meds in exercise), haven't even been training myself (for medical reasons that I'll ultimately describe on ICI - it's a useful case study in how hard it is to provide good medical care for athletes). I've just been so completely disconnected from stuff that, prior to a few months ago, was such a hugely life-defining realm of my world. Somehow, I actually kind-of forgot about it. It's no wonder I've been feeling so useless, tagging along like a puppy in a white coat around a miserable, cold, chaotic place that would be the LAST place I'd want to be if I were really sick (i.e., The Hospital).

It's humbling to think that stuff you do has larger consequences than you intend, sometimes. My sidebar of my other blog, describing how its URL earned its name, says it all. Truth be told, what this person accomplished had very little to do with what she read here -- it's all about serving as the spark that "clicks" people into shifting their own paradigms.

You never know what's going to set people off, get them thinking. You never know what's going to truly speak to people at the very specific place where they're at, to inspire them to choose the direction they want to go. My boyfriend teases me about my redundancy - I speak the way I write, and I write the way I coach (both athletically and medically - and, yes, I do continue to see my role as a physician-in-training as such) -- delivering messages in multiple different ways, with the hope that one particular fragment of one of those messages will be the one that "carries the day" for someone. Because if it doesn't, then what's the point?

Of all the times and contexts in which I've suffered from burn-out, I can honestly say that I've never had this experience as a coach. Sure, there have been times when I'm tired or cranky or sad and want to stay home and nap instead of getting up in front of a room and kicking into "positive life presence mode." But that's not burn-out. Burn-out is being so drained that you temporarily forget your purpose. And if your purpose is to connect with people, to reach them, to share your expertise and passion for the things you believe in -- do it. Even if you don't think it's working.

You're always touching lives, even if you never know it.