Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

How are you . . . really?

"Planting The Seed of The Heart," by David Kopacz.


A helpful practice to connect and understand your patient is to ask, "How are you doing . . . really?” If they’re hesitant to respond, consider sharing something you’ve found stressful lately to open the conversation.

This simple question, asked many times a day in passing, has recently become a lot more complex for me. Below is an example.


At our local pub, Duncan, our server who we get on well with, asked us at our outside table, “How’s everything?” I took a deep breath and then began enumerating the good, the bad, the ok, the terrible . . . my clinical team―don’t even get me started―five people have left the team during the pandemic and leadership decided a pandemic was a good time to re-structure (I would say un-structure) the team, and everything feels very chaotic. When I paused for another breath, Duncan interjected, “I just meant the food.” We had a laugh at this, but it got me thinking about these questions we ask: “How are you doing? How is everything? How are you?”


When I lived and worked in New Zealand, one of my colleagues, Mark, said each day, “You alright?” It always took me back―did I look like something was wrong, was something wrong with my clothes, did something just happen I didn’t know about? I later learned that this was a common way, in a region of England, that people used the perfunctory question as a greeting, “You alright/How are you doing?” The question was really more of a greeting or a social nicety, not really an invitation to launch into how everything is, as I had done with Duncan.


There is a poem by Ghalib, “The Clay Cup,” that has the line, “God thinks―this is a bad mistake―that I’m in good shape.”


Well, Duncan, Mark, God, let me tell you―everything is not alright, I’m not ok, I’m not doing that well. And, yet, there are things that are going well or even great―my new book is about to be published, the garden is beautiful, and a  family member’s biopsies came back benign. Things are, well, complicated and complex.


For a while, I was thinking that my state of complexity of emotion was some kind of problem―was I falling apart, losing my mind, burning out, suffering moral injury? Why was I finding it so difficult to answer this simple question, “How are you doing?” Then I had an insight―maybe it’s ok to feel this way, what Jon Kabat-Zinn, quoting Zorba the Greek, calls “the full catastrophe.”


One thing I’ve done during the pandemic is to enroll in an iRest (Integrative Restoration) certification program. iRest draws from the tradition of yoga nidra (or yogic sleep). It’s a non-dual practice, meaning that part of the practice is to break down dualities of good/bad, happy/sad, and pain/joy. The practice begins with a body scan―how am I currently in my body? Then, what you could call a breath scan―what’s the feeling of the breath breathing the body? Next is an opening to emotion and then thinking. When you get stuck, you work with opposites. You go deeply into a body sensation, an emotional feeling, or a thought, and then you find the opposite of that sensation, emotion, thought, you go back and forth a few times, first one opposite, then the other. Then, and this part always feels a little like a short circuit and a reboot―you work on experiencing both of the opposite sensations, emotions, thoughts at the same time! Try it!


We tend to identify with one thing to the exclusion of other possibilities―I’m sad, or I’m happy, or I’m suffering―yet we are complex, multi-dimensional beings and we can have pain in one part of our body and well-being in another, we can be sad and heavy in our heart, but we can also be optimistic and looking forward to something on the weekend. Non-duality teaches us that we are more than one thing at a time, we can feel everything at once and this expands our perspective and gives a strange kind of relief and resilience. My insight was―maybe this damn yoga nidra is messing me up! Or, to put it another way, maybe the fact that I’m routinely practicing experiencing opposites,  I’m having difficulty breaking my daily life into the opposites that would allow me to quickly and easily answer how I’m doing. When someone asks, “How are you doing?” I don’t really know how to answer―there’s no easy answer, it’s complex and complicated. Instead, maybe I should reply, “Can you handle the truth? Because the truth is complex!”


In one of our whole health education champion meetings, as part of the VA Office of Patient Centered Care & Cultural Transformation, my friend Julia Yates gave us the task on a team breakout: “How are you? How are you . . . really?” Damn, I thought, I just can’t get away from this! Julia is the Director of Behavioral Health and Wellbeing in the Family Medicine & Community Health program at University of Wisconsin. Staff wellness is a strong interest of mine, as it is with all of our whole health education faculty. Sometimes I feel like I should be doing better than I am―I’m a lecturer (I wouldn’t say expert) on staff well-being, shouldn’t my being be better than it is? Well, I’m human and there’s a pandemic, maybe I should cut myself some slack. Maybe we should just end this piece with Julia’s question to us, “How are you? How are you . . . really?”


Here are a few practices you can try: 

1. Reflective writing practice.

Write the question on the top of the page, see how many answers you can come up about different outer dimensions of your life and different inner dimensions of your mind, body, emotions, and spirit.


2. Talking practice.

This can be challenging in these times of social distancing, but online or outside, sit with a friend or family member and ask them the question―then listen, and then swap.


3. Reflective movement practice.

This could be mindful walking, yoga, tai chi, or even washing dishes. As you move, create space for awareness and ask yourself the question, “How am I doing?”


4. Working with pain and suffering practice.

We work with pain and suffering every day at work and we’re bound to have our own as well. You can write about or just think about the following. First, identify the pain and suffering you’ve had in the last day or week. Reflect on how you reacted (usually we react, rather than skillfully working with our pain). Is there a way to work with pain and suffering, a way that you might gain some wisdom, or compassion for yourself and/or others? How can you welcome the inevitable pain and suffering into your life and honor it as a teacher of the human experience?


5. Cultivating joy practice.

This could be considered an opposite, or a paired practice with working with pain and suffering. Once you’ve acknowledged and worked with pain and suffering, you may find that you have some open space in yourself, the ability to shift from pain to joy. What brings you joy? What would bring you joy right now, in this moment? It may be as simple as taking off your shoes and walking barefoot in the grass, listening to a bird, looking at a flower, taking a nap, getting a drink of water, or making your favorite dinner. Joy can be a simple thing, and yet it can be work to make the space for it in our busy lives. Some say that the nature of being is, itself, joy, and that to simply be and breathe can be an experience of joy.


6. Meditation practice.

Simply sit, allow whatever is to be, que sera, sera, whatever will be, will be. Without trying to change anything, practice radical acceptance of reality and radical self-acceptance.


7. Working with opposites practice.

You can do this as I described above, meeting and greeting body sensations, emotions, thoughts, then going deeply into what is present, then looking for its opposite, switching back and forth, and then the practice of experiencing both at once. Here are a few resources you can try, but there are many yoga nidra resources on the internet.


For working with patients:


Ask, “How are you doing?” After listening for a reply, determine if the the patient has more to share. Consider asking, “How are you doing . . . really?



I also find it helpful with patients to share one or two things that I’ve found particularly stressful or trying lately. Or, sometimes I’ll tell them, “You know, I had two other patients earlier today who spoke about similar things. You aren’t alone in this, we’re all struggling through the best we can.”

Contextualizing in this way and normalizing can help people not feel even worse about feeling bad or struggling. I also like saying that in an abnormal situation, it’s normal to feel abnormal!








This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.