“People Don’t Care…

Lily Pad Lake trail weather coming

…how much you know until they know how much you care.”   –Teddy Roosevelt (the most common attribution—but at this point, who knows?)

Friends, I had a great conversation on Facebook this week that really made me think!  I have pasted it below so you can decide what you think of it—please share your impressions, as my own have evolved as I reread it.

I initially shared an article by Ozan Varol entitled, “Facts Don’t Change People’s Minds.  Here’s What Does”.  In it he outlines steps to help others and ourselves change our minds rather than dig in:

  1. Make it psychologically safe to admit they (or we) were wrong before—stop shaming one another for our diverse beliefs
  2. Disentangle ourselves from our beliefs—hold them loosely rather than in identity-defining death grips
  3. Practice empathy
  4. Exit our echo chambers

I thought this was all pretty good, and my friend agreed that the method is effective, and also ‘morally ambiguous.’  At the end of the conversation my understanding of his perspective (again, please see for yourself below) is that he opposes ‘tricking’ people by manipulating their emotions into agreeing with us, while ignoring facts and evidence.  I agree with this opposition, and I also see this article as not actually suggesting we do this.

Basically it got me thinking:  It’s not that we can either argue/convince with facts or we can’t.  It’s that we have to make a personal, emotional connection before someone in opposition can be open to our facts and evidence.  This is not an either/or proposition.  It is both/and, as most things are.

After the two-day thread concluded I felt an urge to listen again to Never Split the Difference, a book on negotiation by Chris Voss, a former FBI hostage negotiator.  Funny how that came up…  In it he references Daniel Kahneman’s book, Thinking, Fast and Slow.  Kahneman describes two aspects of mind, System I, our intuitive, limbic, subconscious mind, and System II, our rational, logical, cognitive mind.  Voss’s and the FBI’s most successful negotiation strategies are founded on the understanding that System I is the primary driver of human behavior and action, though we would like to think otherwise.  This reminded me of Jonathan Haidt’s analogy of the mind as an elephant (System I) and a rider (System II).  He also posits that though we assume the rider steers the elephant, really the elephant goes where it wants and the rider rationalizes the path.

None of this is meant as a negative judgment on humanity or to say that we are not the super-intelligent, creative, and highest order creatures we claim to be.  It is simply the reality of how our minds work, a consequence of evolution for individual survival and tribal living.  When confronted with someone I perceive as an enemy (someone who shames me, threatens my sense of self and belonging, even if unintentionally), why in the world would I open my mind and experience to her point of view, even it would benefit me in practical terms?  Under threat of attack (of my ideas, beliefs, and identity), the elephant will stampede and trample, not stop, put its snout to its forehead, and consider thoughtfully.  But if my own tribe member, whom I already trust implicitly and with whom I feel relaxed and open, encourages me to change our usual path to the water hole because she has found one that bypasses the lion pride, I am far more open to the idea.

Similarly, if we consider ‘changing our minds’ as analogous to behavior change, we see how knowing the facts and evidence is definitely not enough to change anything.  I know I should eat less if I want to lose weight.  I know added sugars and simple starches are not healthful staples for my diet.  I know that eating late wrecks my metabolism.  So why do I still eat big, yummy brownies at 10PM?  Some days I can muster the motivation to head off self-sabotage; other days not so much.  I stress eat, especially when I’m sleep deprived.  So now I’m also listening again to Chip and Dan Heath’s book Switch: How to Change Things When Change Is Hard.  They propose a three-pronged approach to behavior change at the individual, organizational, and societal levels:  1. Direct the Rider (know the facts and have them ready to present).  2. Motivate the Elephant (find meaning for motivation).  3. Shape the Path (make it easy, remove obstacles).  All of these articles and books reflect the same reality: we are emotional beings who think, in that order.

Of course changing people’s minds, especially about emotionally charged and controversial ideas, is hard!  And of course facts and evidence are crucial and we absolutely should not ignore or abondon them!  And, we would all benefit from practicing a little more generosity, patience, empathy, kindness, and charity in our approach to one another—whether we’re trying to change minds or not.

 

*    *   *   *

CC

Friends, please read.
Applies to vaccines, politics, family conflicts, and relationship communication in general.

 

JM

I’m a total believer in the successfulness of this philosophy as a general rule, and I also find it Machiavellian and morally troubling. A great many people have a severely limited ability to understand the facts they believe. They can hold contradictory views easily and they prize simplistic notions of tribal loyalty, common sense vs actual knowledge and nostalgia for a past that never existed. Until we prize critical thinking as a a skill, we won’t display it as a people. And of course, this article correctly but tragically argues that since we don’t, and since we all just walk along blasting confirmation bias all over the place, it’s pointless to attempt persuasion with critical thinking skills and one should instead seek to trick people into doing what’s right through revisionist personal histories (you aren’t responsible for your past failures in critical thinking) and personalized sales pitches (who cares about the principled notions of the greater good or what’s just! Let’s talk about you and your family’s short term best interests!)

 

CC

Thanks, Jonathan. I wonder what you think of this post that I wrote, then?https://catherinechengmd.com/…/talking-to-the-opposed…/

 

JM

In this article you don’t have a clearly stated goal. So while I gather that you support vaccination, you don’t seem too bothered by patients who opt not to vaccinate. I see this as raising a question. If you learned that a parent was deliberately harming a child you wouldn’t casually suggest the idea that next year you revisit the benefits of not abusing kids. You’d act. You’d report. You’d get authorities involved. You’d protect the kids, even against the parents wishes. And you would do it now. So as I said, it raises the question: how bad is it to not vaccinate? Your article implies that it’s not that bad. In fact, you give two examples of outcomes: one of a child who gets autism and one of a child who gets whooping cough. Can you see how this implies balance in the perspectives? Are these views equally valid? Sympathy towards the emotional struggle of making the right decisions for kids should not be conflated with sympathy for endangering children -both one’s own and others in the community. Is there reasonable doubt about whether vaccines cause autism or not? That’s not only testable but actually repeatedly and widely tested already. Let me state it in reverse: I currently vaccinate but if verifiable scientific evidence started raining doubts about whether vaccines caused autism, I would want my doctor to tell me ASAP and explain it emphatically and with little regard to my previously erroneously held belief.

 

CC 

Thanks for your feedback, Jonathan. I actually do state a clear goal: “my primary objective is actually to cultivate our relationship.” Of course I think it’s harmful to both the child and the community to not vaccinate. I am absolutely bothered by non- and anti-vaxxers (as evidenced by multiple posts on this page). And I also have to take into account the likely outcomes of my actions. My goal is to get everybody vaccinated, no question. But demanding it now, as if it’s really the same as witnessing a parent beating a child physically, is not often productive. I have learned in multiple relationship settings that chasing agreement and acquiescence gets me the opposite result. In this case, taking the long view and strategy, with a soft front, works.  Just this flu season, I estimate my ‘conversion’ rate at about 60-70%, which I assess as successful. And I did so while maintaining and strengthening the physician-patient relationship, which is even better. And for those who continue to defer vaccination, at least they are still with me and I have more chances to continue the conversation and eventually make an impact. To me that’s worth a little waiting in the short term, which could be long term waiting and making people dig in harder against, if I came at them too aggressively.

 

JM

all that sounds great. My comments were only about that article, not your actions.

 

CC

Huh, okay… The article I wrote speaks directly to my actions, so I am not sure what the distinction is? Regardless, I respect your opinion so I hope I have your confidence in me as a physician and a steward of public health.

 

JM

you do!
—next day—

CC

 I’m beating the dead horse! Feel free to ignore. Here is an article along the same lines, which I saved at the time it was published. Interesting to read it again now.https://hbr.org/…/how-to-build-an-exit-ramp-for-trump…

 

JM

Yup. Same deal. Machiavellian. Ends justify means. Critical thinking is not taught or valued so let’s ditch it in favor of methods that are effective at achieving the desired result. That may actually achieve the most social good in the end. But it’s still morally ambiguous. When does an elephant in the room become so large that you simply can’t claim not to have seen it? Must we always pretend that it’s reasonable to have thought it was a grey desk to give people an out? These articles seem to say yes. They might be right. I’m just not happy about it.

 

Oh, and I do apply this to “both sides”. There is a position I’ve heard espoused on the Left that argues that holding people accountable for stupidity is a form of prejudice. <insert shock face emoji here> It’s apparently “ableist”. And that it’s inappropriate to expect people to all be able to reason and know things. Any things. That one leaves me speechless. It seems more about a race to decry the most possible prejudices than an attempt to help improve our world. Virtue signaling. I’M SO WOKE! I’M EVEN MORE WOKE! I WOKE UP WOKE!

 

CC

Thank you for engaging, Jonathan! Your perspective is so interesting to me, I don’t see it these strategies as nearly as manipulative as you see them. To me, they are enlightening paths of empathy, leading to clearer and more compassionate, understanding communication. Underlying the methods I see an implication that we all may be more open-minded than we know, if given space and connection to explore alternative perspectives to our own. The methods themselves are simply a way to uncover and allow that openness, and thus possibility for change and growth, to emerge. If one practices these strategies with NO commitment to a particular outcome, but simply for the sake of continuing a conversation or relationship–an exchange of perspectives for mutual understanding and respect–if we all practiced this we all might end up changing, little by little, for the better, and better together.

 

JM

We’d be more open to dialogue in the non-judgmental world you describe. But, while it’s popular to embrace profound egalitarianism as positive, that is a disaster in practice. Not every viewpoint should enjoy the same privileges. For instance, slavery is a viewpoint. Might makes right is a viewpoint. The Nazis had a viewpoint. Should these all be engaged with with respect for a differing worldview? I don’t think so. Determining your actual reason for why not is key. It’s because we believe deep down in hierarchies. Even egalitarians tend to believe that egalitarianism is BETTER than non-egalitarianism. There is a Buddhist parable in which the student asks: “If we meet bandits on the road, and they try to kills us, how are we to act compassionately as our noble truths dictate?” The teacher answers “You must cut them down with your sword, compassionately.”

 

CC

I agree with everything you write here. But is this not a tangent? Do any of these articles or any of my comments claim that all viewpoints are equal? This conversation is not about ‘profound egalitarianism’ and its merits or lack thereof. Being slightly more open minded and empathetic toward our fellow humans (which is the point of these articles, in my view) does not equal throwing away all forms of morality and ethics, absolving ourselves of any and all judgment, or elevating slavery, xenophobia, and genocide to anything remotely acceptable. So I’m curious. When you encounter people whose opinion or whatever is opposed to your own, how do you engage? What are your objectives when you interact with them on these topics? For instance on this thread–why are you still here? You go first and then I’ll tell you mine. 

 

JM

Firstly, I’m arguing from the edges. Is an approach sound? You can test it by how it handles just such situations. The articles discuss a successful methodology for achieving a change in position. You can describe that most generously as sympathetic openness combined with non-confrontation. That is presented for its effectiveness. When I engage with people with differing opinions, it matters greatly what the opinions are. I evaluate them based on the soundness of the facts and theory underlying them. When more sound than my own, I change my views. When less sound, I can safely place them back in the bin of the disproven, false or less effective. I’m typically delighted to be convinced of a new position. I don’t view all positions as being basically equal. I view positions as very often being hierarchical. Some are intrinsically better than others. That means when I change position for just reasons, I am improving myself and the world at large. My engagement here is based on the warmth of our relationship and the desire to see higher truths recognized wherever possible -the ultimate purpose of information exchange. If the real purpose of the articles is to “be suuuuuuper nice before and while presenting your logic” then that’s just “getting more bees with honey than vinegar”. I don’t disagree. But some part reads to me like an acceptance of tribalism. In other words, this system doesn’t increase the likelihood of the “right” answer or the just answer. Just the answer of the person most effectively using the technique.

 

CC

THANK YOU, I understand you much better now!! I very much appreciate what you wrote here, and I wholeheartedly agree, especially with the self-improvement part. You have elevated my point of view and I will refer back to this conversation often now! So on my end, I engaged because I noticed myself feeling defensive and I wanted to understand what I was feeling a need to defend against. Now I don’t feel defensive at all, and I am so glad we continued the exchange! Big hugs, old friend! 😀

 

Synthesis and Integration: Self and Other Focus

DSC_0439

Hey friends, how was your week?  Learn anything new and interesting?  Anneal any new ideas to existing frameworks in your already complex world view?  I did!  And it came in another big wave after my presentation on Friday.

I wrote last week about how I put together a new presentation.  For the first time, I added the idea of medicine as a complex adaptive system to a talk I gave to physicians at various levels of training and practice.  The objective of the presentation was for people to understand the scope of physician burnout, and leave with some ideas of how they could not only cope better themselves today, but also influence the system and move it toward a healthier, more compassionate state in the future.

As usual for my talks, I focused first on personal resilience.  Many physicians push back at this idea, and rightly so, as many medical organizations have instituted physician wellness programs aimed mainly at ‘fixing’ the doctors with yoga and meditation classes, while allowing the system that burns them out to continue its toxic trends toward over-regulation, loss of physician autonomy, and driving metrics that lie outside of, or even counter to, our core values.  I worried that my talk would be taken as just another attempt to tell physicians we aren’t good enough at self-care.

Thankfully, the feedback so far has been positive and I have not heard anyone say they felt berated or shamed.  I hope it’s because in addition to tips for self-care (eg 7 minute workout, picnic plate method of eating), I talked about how each of us can actually help change the system.  In a complex system, each individual (a ‘node’) is connected to each other individual, directly or indirectly.  So, difficult as it may be to see in medicine, everything I do affects all others, and everything each other does affects me.  This means I can be a victim and an agent at the same time, and the more I choose one or the other (when I am able to choose), I actively, if unintentionally, contribute to the self-organizing system moving in one direction or another [URL credit for image below pending].

Nodes in Complex System

My primary objective in every presentation is to inspire each member of my audience to claim their agency.  Before that can happen we must recognize that we have any agency to begin with, then shore up our resources to exercise it (self-care and relationships), and then decide where, when, and how that agency is best directed.

 

In 5 years of PowerPoint iterations, including and excluding certain concepts, I have always incorporated David Logan’s framework of stages of tribal culture.  Basically there are 5 stages, 1-3 being low functioning, and 4-5 high functioning.  The tribal mantras for the first three stages are, respectively, “Live sucks,” “My life sucks,” and “I’m great”.  Stage four tribes say, “We’re great” and in stage 5 we say, “Life’s great.”  The gap between stages 3 and 4 is wide, as evidenced by the traffic jam of people and tribes at the third stage.  In my view, the difference is mindset.  In the first three stages, most individuals’ implicit focus is on self, and subconscious mindset centers around scarcity and competition.  Victims abound in these cultures, as we focus on recognition, advancement, and getting ours.  We cross the chasm when we are able to step back and recognize how our mutual connections and how we cultivate them make us better—together—we see the network surrounding and tied to our lone-node-selves.

This week I realized that crossing the stage 3-to-4 chasm relates to two frameworks I learned recently:

The way I see it, in Logan’s tribal culture structure, one initially works toward self-actualization, essentially achieving it when fully inhabiting stage 3, “I’m great.”  But crossing to stage 4 requires self-transcendence, as described by Abraham Maslow, by recognizing a greater purpose for one’s existence than simply advancing self-interest.  In the same way, through stage 3 we live in what the Arbinger Institute describes as an ‘inward mindset,’ and we cross to stage 4 when we acquire an ‘outward mindset’, which is pretty much what it sounds like.  Essentially in stage 3 we mostly say, “I’m great, and I’m surrounded by idiots,” and in stages 4 and 5 the prevailing sentiment resembles, “We’re great, life’s great, and I’m so happy to be here, grateful for the opportunity to contribute.”

An astute colleague pointed out during my talk on Friday that we do not live strictly in one stage or mindset in serial fashion.  Depending on circumstances, context, and yes, state of mind and body (hence the importance of self-care!), we move freely and maybe often between stages, sometimes in the very same conversation!  The goals are to 1) look for role models to lead us to higher functioning stages more of the time, and 2) model for others around us to climb the tribal culture mountain with us, spending more and more mindset and energy at higher and higher stages.

The problem is the system, and we are the system.  So, onward.  Progress moves slowly and inevitably.  It will take time, energy, and collective effort.

We’ got this.

Attune and Attend, Conclusion

546782_4331875609644_1120262410_n

Two posts ago, I related my friend’s experience of feeling unseen and dismissed during a visit to establish care with her new primary care doctor.  I blamed the doctor for not listening, for not exercising his relationship power with enough responsibility.  Last week I described how I see medicine as a complex system, in which each of us is both a contributory and affected member.  I alluded in both posts to forthcoming ‘solutions. ‘

If you have read the last two posts, what were you expecting here, in the last installment?  Quite honestly, the closer I came to writing, the more nervous I got, as if I had promised to deliver some groundbreaking algorithm for instantly fixing physician-patient relationships and our healthcare system at large.  Um, no, sorry.  Hopefully what I write will still be useful.

Events these past weeks have really highlighted for me the profound importance and vulnerability of relationships in a system.  At my kids’ school, a veteran and beloved teacher was terminated suddenly.  No students, staff, faculty or parents were given any warning.  Communication was sparse and poor, and few if any in the community saw evidence of a plan for instruction and emotional support of students in the aftermath.  Students, faculty, and parents alike have raised questions and concerns, all, in my opinion, met with evasion and deflection.  Worst of all, the administration repeatedly refused to acknowledge or own the profoundly negative impact of their actions on their relationships with the school community—a community which they proudly claim to steward.

Once trust has been violated and relationships damaged, the road to recovery looms long and ardent.  Apologies—sincere and heartfelt—serve a necessary and vital role in repair, but they are only the beginning.  We all make mistakes.  But too few of us own up to them and take full responsibility, especially when we have hurt others.  In a medical or educational community, I think we focus too much on scientific and objective decision making, and too little on relationships.  That is to say, we manage the former very intentionally and critically, and the latter only in passing.  This is how, for instance, a surgeon ends up saying to patients, “I can’t help you,” when surgery is not a viable treatment option.  We can always help.

In recent months I have listened to and read myriad resources that point me to some simple (and not easy) guideposts for relationship cultivation and repair.  I have listed the guideposts and their references below.  None of them will surprise you.  You may even roll your eyes and think them cliché.  And yet, all of us in all of our overlapping systems and tribes could do a little better at these practices—physicians and patients, teachers and students, leaders and those they lead.  Which one will you attune and attend to now?  What else should be on the list?

 

Curiosity

By its nature, curiosity makes us open and willing to see more, learn more, and understand more.  What if we got more curious about other people’s feelings and their origins?  What if we did that for ourselves?  Why, for instance, do I get angry when I perceive someone trying to tell me what to do without asking first what I’m thinking?  Could they be motivated by something other than a desire to control and oppress me?  How else could I respond if I thought they were trying to help me solve a problem, if I interpreted their actions as caring rather than interfering?  Check out the distinctions between diversive, epistemic, and empathic curiosity described by Ian Leslie below.  Then the next time you feel conflict coming on, consider these questions (asked in a truly curious tone):

What is this about?

Huh, what else?

Curious, by Ian Leslie

The Art of Possibility by RS and B Zander

Rising Strong and Dare to Lead by Brené Brown.

Kindness

Smiling at a stranger, extending a hand to shake, holding a door, saying hello—small acts of kindness go such a long way.  They benefit not only the recipient and the actor, but also bystanders and witnesses.  Kindness is a primary currency of connection, and reserves can be infinite.  We should never underestimate the potential tidal waves of global benefit from our dropping a pebble of kindness in the waters of humanity.  When a stranger holds the door or my patient asks about my kids, in that moment I feel seen.  I connect with you, my kind counterpart.  My heart lifts ever so slightly, and I am grateful.

A Year of Living Kindly, blog and book by Donna Cameron

Forgiveness

Forgiveness can feel infinitely harder than small acts of kindness.  Will my friend forgive her doctor?  Will I forgive my kids’ school administrators?  What good does it do to carry around grudges, does that get us what we want?  Where else can we direct the energy we expend holding so tightly to resentment?  Could we use it instead to ask, honestly, “What is this about?” or to utter a kind, compassionate word?  Can we see people as people, flawed and trying their best, rather than objects, obstructions, annoyances, and unworthy?

TED Radio Hour, Forgiveness

Leadership and Self-Deception and The Anatomy of Peace by The Arbinger Institute

Accountability

When I hit and dent a parked car, I should leave a note owning my mistake and offering to make up for it—even if I slid on ice, or my child was crying in the back seat, or the other person’s car was parked poorly.  If someone damages my car, I expect the same.  The more we can all/each take responsibility for our own part in any conflict or situation, no more and no less, the better off we will all be.  The key here, when we show up to others, is to do it without qualification.  It’s not, “Yes, I hit your car, but…”  It’s, “I hit your car.  I’m sorry.  How can I make it right?”  I may think you were also in the wrong, but pointing that out in the middle of an argument will not help you own your part, which I need you to do for us to connect and heal.  You may never own your part, and I have no control over that.   But perhaps my example will influence you or others over time.  Humans tend to reciprocate, and mutual exchange of accountability can heal many relationship wounds.

7 Truths About Accountability That You Need to Know”, Inc.com

Humility

Nobody knows everything, even experts.  And certainly when meeting another human, we cannot possibly know all that has shaped their beliefs, values, and emotions, both in the past and in the moment.  In medicine we have never known more than we do today, and it seems to me that for every new piece of knowledge we acquire, we also discover a hundred new things we didn’t know we didn’t know.  So what gives me the right to assume I have all the answers—that I have nothing to gain or learn by asking curiosity questions?  Why should I feel the need to appear all-knowing?  The opposite of humility is arrogance, and we all know how hard it is to be around people like this.  Turns out students and leaders alike, who practice humility, succeed more than their less humble peers.  Makes sense—humility connects us to others, while arrogance separates.  It’s vulnerable, though, and that can be uncomfortable.  But if we have already cultivated our relationships with curiosity, kindness, forgiveness and accountability, perhaps humility can come a bit more easily.

“The Benefits of Admitting When You Don’t Know” by Tenelle Porter

Empathy

In the end, I believe empathy will save us.  It is the bedrock on which the other skills are built.  Google dictionary defines empathy as “the ability to understand and share the feelings of another.”  It will save us because this is how we truly connect to one another.  But it’s not enough to just have the ability to understand and share others’ feelings.  In order for empathy to connect us, we also need to effectively express that understanding and share the emotions actively.  Active empathy allows us to take another person’s perspective.  It keeps us out of judgment and blame.  It helps us recognize others’ emotions by recognizing our own familiar experiences—empathy is how we relate.  It is the medium of relationship.  Some people possess the gift intuitively.  And it can be learned!  Medical training programs across the country have taught doctors how to be more empathic.  Patients of more empathic physicians do better.  And, physicians themselves do better, too–we feel less burned out and more fulfilled in our work.  We all do better when we connect.

Watch a cartoon and hear Brené Brown explain the importance and benefits of empathy.

“How to Teach Doctors Empathy” by Sandra Boodman

The Empathy Effect by Helen Reiss, MD

 

Please forgive the length this time, friends.

What did you think?  In your next encounter with your doctor or your boss, what do you anticipate?  What do you fear?  How does it feel?  What is that about?  Which of these skills could help?  How will you acquire/hone it?  What help do you need?  What will be better if you achieve it?

What else should be on the list?

Attune and Attend, Continued

dsc_0755

Last week I started and ended my post incensed on behalf of my friend, who felt coldly and arrogantly dismissed by her new doctor.  While I considered that his behavior may be influenced by his circumstances and did not attack his character or make generalizations based on gender, age, etc., I did blame him individually for how my friend felt in his presence.

Another friend read the post and said the doctor was not to blame, rather it’s the system.  We exchanged thoughts and agreed that it was not all the doctor’s fault, and the whole healthcare system in our country is just a big mess in general.  I continue to have daily conversations around physician well-being and systems transformation in medicine, and every single encounter advances my understanding of and awe at the whole situation.  Here are my most current thoughts—bear with me, please.

3 Reciprocal Domains of Professional Fulfillment

Most of us working in the physician well-being space have adopted a model for professional fulfillment developed by our colleagues at Stanford.  If you care at all about your doctors’ professional health and how that impacts the care they deliver, I encourage you to read this article that describes their approach.  In it, they define efficiency of practice (eg team workflow, electronic health record use and misuse, systems bureaucracy), culture of wellness (institutional attitudes that advocate for self-care, peer support, and mutual compassion between team members and patients), and personal resilience (individual skills and behaviors that promote personal well-being) as the three mutually influencing factors that determine, for individuals as well as organizations, our overall professional health and well-being:

The many drivers of both burnout and high professional fulfillment fall into three major domains: efficiency of practice, a culture of wellness, and personal resilience… Each domain reciprocally influences the others; thus, a balanced approach is necessary to build a stable platform that will drive sustained improvements in physician well-being and the performance of our health care systems.

For the record, I fully concur with this approach, and with one of the authors whom I met at the international conference in Toronto, that the most important parts of the framework are the arrows reminding us always to look for how the domains intersect and influence one another.

We Are the System

In the article, the authors write, “Efficiency of practice and a culture of wellness are primarily organizational responsibilities, whereas maintaining personal resilience is primarily the obligation of the individual physician.”  This is where I differ somewhat.  I fully agree that an organization’s culture is set at the top.  Designated leaders lead by example, admit it or not, like it or not.  They (and we—all doctors bear this responsibility on any given care team) provide cues for acceptable and unacceptable behavior, positive and negative.

That said, a team or an organization’s culture is executed and manifested day to day, moment to moment, in every interaction, by each individual within the system.  This is the essence of complex systems—they are self-organizing at a global level (hence soon after joining a group we find ourselves adapting to fit in), and also emergent and evolutionary at the granular level (one person can turn a place around over time—have you seen it?).  So in my opinion, both leaders and individuals are responsible for creating and maintaining the Culture of Wellness in medicine.  We are the system.  If you’re interested in more of what I think about this, check out this podcast from September 2018 when I presented to the surgeons and anesthesiologists at the University of Wisconsin at Madison.

In a Complex System, It’s All About Relationships

A person is a complex system.  In my practice (and in my own life) I try always to attend to the relationships between 5 reciprocal domains (labelled intentionally after the Stanford model) of health: Sleep, Exercise, Nutrition, Stress Management, and Relationships.  How do they relate?  When I don’t get enough sleep I tend to overeat; when I eat too much I feel sluggish and unmotivated to exercise.  When I exercise less I am more susceptible to stress, which puts my relationships at risk, which then disrupts my sleep, and the downward spiral persists.

A patient care team, a medical practice, a hospital—these are all complex systems.  Besides the three domains in the Stanford model, what other factors contribute to the self-organizing nature of such systems?  Perhaps individual autonomy, collective loyalty, shared mission, attention to training, and communication?  What inter-relational factors dictate an individual’s or a subgroup’s behavior, and how does that influence the whole organization?

I am reminded of starlings in a murmuration, or sardines in a school.  Seen from afar, the mass of animals appears to move as one agile and sentient organism.  In reality, each animal’s movement is at once independent of and intimately tied to those in its immediate vicinity.  Each animal’s awareness of and response to its neighbors are acute and instantaneous, respectively, and thus the collective is able to evade predators and give humans insight into what true multi-mutual cooperation looks like.  They are attuned.  This is possible because, according to science:

The change in the behavioral state of one animal affects and is affected by that of all other animals in the group, no matter how large the group is. Scale-free correlations provide each animal with an effective perception range much larger than the direct interindividual interaction range, thus enhancing global response to perturbations.

Would your organization, seen from afar, appear as organized and fluid as a flock of murmuring starlings?  What would it require in order to do so?

* * * *

So what does this mean for my friend and how she (and we all) should think about doctors and our healthcare system in general?  How does this actually relate to solutions to the problems I presented last week?  Clearly, as I beat the long dead horse again and again, it’s about relationships, of course.  But we have to think more deeply than just about our behaviors and actions—we’ gotta buckle up and dive into their origins—spelunk our default orientations toward self and others, our automatic settings, and how they manifest in our relationships and create, intentionally and not, our collective systems.

Once again, I have hit 1000 words on this post and it’s late.  I’m getting there, I promise—not that I have the solution!  I’m simply learning and synthesizing more every week about how we can more consciously and mindfully approach the problem.  It has everything to do with the books I started reading recently about complexity, leadership, and mindset, and how they help me see my conversations and relationships in a new, exciting light.

More next week, friends!

Attune and Attend

dsc_0450

My friends, I am offended.  I’m insulted and frustrated.  Part of me screams, stomps, and rages inside.

I am embarrassed.

My friend went to establish care with a new primary care physician last week.  Before the appointment she was told to bring all of her medical records.  No instructions, no specification of which parts or in what form.  So, being the tech-savvy and eco-friendly woman she is, she downloaded all that was available to her onto a thumb drive, as it was rather copious now in her 7th decade of life.

Upon arrival, she presented the drive to the woman who initiated the evaluation.  She thinks this was a nurse; but she’s not sure.  The woman said she could not ‘handle’ the thumb drive, but said, “I can just pull it up here online.”  What?  Ok whatever, clearly the medical record request was simply a routine request made of all new patients.  Thereafter the woman proceeded through routine medical questioning.  But as my friend answered the interrogation, she felt distinctly ignored.  Her concerns were not addressed and she did not feel any rapport.  The woman did an EKG and left the exam room.

Later, while my friend was still sitting on the exam table, the woman returned with an old man in a white coat.  He stood there, hands behind his back, and informed my friend they had called for an ambulance to take her to the emergency department.   The EKG showed an abnormal heart rhythm.  They said she would likely be in the hospital for two days for observation and tests.  The nurse and doctor spoke to each other but not to my friend.  They did not ask her how she was feeling, or what she knew about the/her condition, and they did not check the online record for evidence of past evaluations or recommendations.

My friend refused, for various reasons, not the least of which was that this condition had already been thoroughly evaluated, multiple times, and was actually well controlled.  But the doctor and nurse showed no interest in knowing my friend, nor did they seem to care to include her in any medical decision they made about (for) her.

Granted, this is my friend’s side of the story.  But for right now this is where I focus, because her experience is all too common, and I hate it.  She experienced everything that makes physicians and our healthcare system look and feel so broken, and that contributes to the widening relationship gap between patients and physicians/providers.

She was asked to bring her records, she put forth the effort to do so, and they were not reviewed.

She felt ignored and dismissed, even though the objective of the visit was to establish care and initiate a long term, collaborative relationship with a new primary care doctor.

She was ordered to submit to an ambulance transfer to a hospital emergency department, with neither discussion nor negotiation of other care options, and without regard to the financial and other costs to her.

She felt harassed by the office in the following days, receiving calls admonishing her for not presenting herself to the emergency department.

The bottom line is that my friend felt completely unseen in this encounter.  She felt treated like an object—a set of data, a statistic, a box on a flowchart.  Context, history, and individuality be damned.  When you’re in a relationship with someone who is supposed to help you, on whom you rely to help you understand the best plan of care for you personally, feeling unseen, dismissed, and belittled is exactly the opposite of helpful.

Maybe we should not judge the nurse and doctor too harshly.  We all know the time and volume pressures primary care providers live under these days.  Maybe they were distracted by other, sicker patients they had seen that day.  Maybe that made them more vigilant and aggressive with care recommendations for her, and put them behind schedule so they felt they could not take the time to explain things in more detail.  Maybe the doctor had seen this arrhythmia once before, treated it more casually, and the patient died.  We have no idea.  And it matters, insofar as it impacted how he presented to my friend.  Because his presence was dominating, authoritarian, rigid, and cold.

The patient-physician relationship serves as the foundation for medical care and healing.  No matter how much we talk about and try to honor patient autonomy, the power differential in this relationship remains fixed and real.  The doctor has the power and the responsibility to make the patient feel safe, to earn the patient’s trust.  On this day, in this visit, this doctor blew it, in my opinion.  It was their first encounter.  He should have taken the time and interest to get to know her, even a little, to agree on how they would work together.  If he were truly concerned about her health, knowing she had an arrhythmia (which are often made worse with stress), might he not have noticed the distress he was causing her?  Couldn’t he have given her additional care options, like referring her to a specialist within the week?  Or perhaps he could have opened the electronic health record and looked at her previous cardiologist’s last note?

He did none of these things—or at least not in any way that my friend perceived.

Further, he not only failed to establish a good relationship with her; he undermined her trust in our whole medical system.  How many experiences like this does a person have before she starts to reject the medical community altogether, ignoring symptoms of disease because she would rather deal with pain and disability than try to navigate a hostile system?  Fewer than you might think.  This is how patients end up in emergency rooms with truly life-threatening illness, where, guess what?  They get shamed again for not seeking help sooner.

It’s rather tragic when you think about it.

There is hope, though.  But as this post has already a thousand words, my thoughts on solutions will have to wait.

I hope you all had a restful and joyous holiday season.  My unplanned holiday writing hiatus lasted longer than I intended, and it’s nice to be back.  May we all reconnect with one another in more meaningful, productive, and uplifting ways in 2019.

 

 

Grudges and Boundaries

IMG_0108

Has someone wronged you recently?  Long ago?  (How) Does it still affect you?  Are you a grudge holder?  Does someone hold a grudge against you?

Last night I gathered with good friends and this topic came up—we go deep, my friends and I.  Of course, it started me thinking and wondering:  What does it mean to hold a grudge?  When I hold a grudge, what do I actually do?  What is the motivation?  What are the consequences?  When/how/why does it resolve, if ever?  As we talked, it felt straight forward at first.  Everybody knows how it feels to hold a grudge—but how do you describe or define it?

Google dictionary defines it:

Grudge: /ɡrəj/

noun

a persistent feeling of ill will or resentment resulting from a past insult or injury.

“she held a grudge against her former boss”

synonyms: grievance, resentment, bitterness, rancor, pique, umbrage, dissatisfaction, disgruntlement, bad feelings, hard feelings, ill feelings, ill will, animosity, antipathy, antagonism, enmity, animus;

informala chip on one’s shoulder

“a former employee with a grudge”

verb

be resentfully unwilling to give, grant, or allow (something).

“he grudged the work and time that the meeting involved”

synonyms: begrudge, resent, feel aggrieved about, be resentful of, mind, object to, take exception to, take umbrage at

“he grudges the time the meetings use up”

 

The more we thought about it the worse it felt to me.  I’m reminded of the saying that hatred hurts the hater more than the hated.  Grudges feel like dark clouds hanging over my consciousness, chilling my soul, or at least casting a cold shadow on my joy, freedom of emotion, and possibility for connection.  My friends and I contemplated the utility of grudge holding.   What good does it do, what need does it meet?  I think it’s protective—a defense mechanism, a way of not being vulnerable again—armor, as I believe Brené Brown would call it.

I asked my friends last night, “So is it holding a grudge, or is it setting a boundary?”  I wondered if they are the same or different.  After all, both make you behave differently toward the other person.  But I think it matters whether and how we judge the other person.  When I hold a grudge, I judge the whole person based on the bad thing (I perceive) they did to me.  I may generalize from my own negative experience and write them off as wholly selfish, ignorant, narcissistic, and unworthy of my compassion and empathy.  Perhaps I start to depersonalize them, make them into an abstraction right in front of my eyes—dehumanize them.  Does that seem like an extreme description?  Even so, doesn’t it still describe the feeling?   When I hold a grudge, I do not—cannot—like or even relate to the person.  I avoid them, don’t want to be in the same room with them.  I don’t trust them.

I listened to The Thin Book of Trust by by Charles Feltman (referenced by Brown in her book Dare to Lead) this past week.  He describes four distinctions of trust:  Sincerity, Reliability, Competence, and Caring.  He suggests that when we find someone else untrustworthy, it’s likely that they have disappointed us in one or more of these elements.  I have assumed for a long time that the person I hold a grudge against simply does not care about me or my well-being.  Feltman suggests that of the four distinctions, this may be the hardest one to overcome when violated.  My story about this person is that they don’t care about me, therefore they are categorically untrustworthy.  So I feel justified in denying the validity of their point of view, minimizing their achievements, and casting them as the permanent villain in my story.

Yuck.  That perspective does not align with my core values.

So what can I do?  Maybe rather than holding a grudge, I can simply reorient myself to our relationship.  Instead of harboring bitterness and ill will, can I instead learn, synthesize, and integrate some new information?  When I’m wronged, maybe I can say, with curiosity more than resentment, “How fascinating!”  Maybe I can take care of my own feelings, connect with people I do trust, and regroup.  Then I can decide how I want to present to this person hereafter.  I can set some new boundaries.

Rather than dismiss the person as uncaring in general and holding this against them, I can do other things.  First, I can withhold judgment on their caring and make a more generous assumption.  For example, I feel un-cared for by them, but perhaps their way of expressing caring is different from how I receive it.  I can look for alternative signs of caring.  Or perhaps they truly don’t care about me, but I need to work with them anyway, so I had better figure out a way to do it—are they at least sincere, reliable, and competent?  How must I attend to myself, so I can honor my core values, get the work done, and not get hurt (or at least minimize the risk)?  Second, I can set clear boundaries in our relationship.  I can point out behaviors that I will not tolerate, and call them out if they happen.  I can set realistic expectations about agendas, objectives, methods, and contact.  I can give honest and direct feedback with concrete examples of words or actions that require attention and remedy.

Many thanks to my thoughtful and engaging friends who stimulate these explorations.  I can feel my grip on the grudge loosening already.

Recentering—Vaccine post #3

IMG_4476

NaBloPoMo 2018:  What I’m Learning

When you buy a red car suddenly you notice so many red cars on the road.  I write two posts on vaccines, and now I see all these vaccine posts on my Facebook feed. One made me sad for multiple reasons.

Dr. Jennifer Chuang , a pediatrician who ran for the state legislature in New Jersey, posted this:

In 2017, I was moved to run for office in the NJ State legislature because of bills being introduced that were harmful to public health. Among the areas that I stood firm on were the importance and safety of vaccinations, and I was harshly attacked for that, even threatened.
However, NJ should not be proud of introducing the most pieces of legislation that would have made our children at risk for vaccine preventable illnesses. The current measles outbreak in New Jersey has now grown to 18 cases. Legislative decisions have consequences, especially to public health.

“From 2011 to 2017, New Jersey lawmakers introduced the most pieces of legislation that would make it easier for children to skip vaccines, according to a new study by Drexel University researchers.”

She linked to this article, detailing the anti-vaccine legislative history in New Jersey and lawmakers’ rationale, compared to the scientific literature.

I’m sad that there is such a fight against proven public health initiatives, and I’m sad that legislative bodies, who write our health and medical policies, include remarkably few clinicians.  But I’m most sad at the meanness in the fights.

A woman immediately commented, “Shut up already” on Dr. Chuang’s page.  When challenged benignly by others, she replied telling them to fuck off and calling them assholes.  Her page is apparently public, so I visited.  The posts that I could see were vehemently opposed to vaccines of all kinds, at least in 2016 and 2017.  She apparently lost a son this year, in his 24th year of life.  She has posted about eating healthy, self-care, and seeing intelligence as ‘not because you think you know everything without questioning, but rather because you question everything you think you know.”  So while I feel acutely put off and dismissive of her vile reaction to Dr. Chuang’s post, I also imagine that she and I may have things in common and might even be friends, if circumstances facilitated.

Somehow I came across another woman’s page tonight, similarly militantly anti-vaccine.  She and the first woman both posted a lot of memes and sayings implying that people who advocate for vaccines are brainwashed and ignorant, and not worthy of engagement.  Huh.  Sounds to me just like many of the ad hominems hurled by vaccine advocates against women like them.  It’s exhausting.  Who does it help, this mutual shit-flinging?  In Rising Strong, Brené Brown points out the pitfalls of false dichotomies and binary decision trees.  If you hear people shouting that you have to choose one side or another, that it’s all or nothing, be suspicious.  Look for the beneficiaries of that feud.  Often it’s the politicians who leverage our warring tendencies to stay in office.  Or maybe it’s physicians who, when they refuse to care for patients who decline vaccines, can feel decisively self-righteous rather than uncomfortably ambivalent.  Or maybe it’s the anti-vaccine parent, who feels embarrassed to express fear and uncertainty (because she has been shamed too many times for questioning a sanctimonious medical community), and so finds her voice in combative rage instead.  And could it be that anytime one of us shows up in attack mode, we incite our counterpart to take a mirroring stance, even if that was not their original intent (this is a rhetorical question)?

Regardless, I’m tired.  Social media and loud, mean, public debate are not venues that yield any meaningful interactions (I see the irony of my writing this on a blog).  It feels too slow, but experience teaches me that we win hearts and minds face to face, quietly, intimately.  Nothing good ever comes from a collision of two oncoming bullet trains.  It’s wildly destructive more than anything else.

Thankfully, my good friend posted Max Ehrmann’s poem “Desiderata” tonight.  I first read, transcribed, and posted this poem on my wall in high school, and have not seen it in a couple decades.  It really captures the essence of inner peace and right relationship, with self, humanity, and the earth, and it soothes me.  It’s a late Thursday night of another long week.  I leave you with Mr. Ehrmann’s master work below.  Good night.

Desiderata

Go placidly amid the noise and haste,
and remember what peace there may be in silence.
As far as possible without surrender
be on good terms with all persons.
Speak your truth quietly and clearly;
and listen to others,
even the dull and the ignorant;
they too have their story.

Avoid loud and aggressive persons,
they are vexations to the spirit.
If you compare yourself with others,
you may become vain and bitter;
for always there will be greater and lesser persons than yourself.
Enjoy your achievements as well as your plans.

Keep interested in your own career, however humble;
it is a real possession in the changing fortunes of time.
Exercise caution in your business affairs;
for the world is full of trickery.
But let this not blind you to what virtue there is;
many persons strive for high ideals;
and everywhere life is full of heroism.

Be yourself.
Especially, do not feign affection.
Neither be cynical about love;
for in the face of all aridity and disenchantment
it is as perennial as the grass.

Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.
Beyond a wholesome discipline,
be gentle with yourself.

You are a child of the universe,
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.

Therefore be at peace with God,
whatever you conceive Him to be,
and whatever your labors and aspirations,
in the noisy confusion of life keep peace with your soul.

With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful.
Strive to be happy.

Max Ehrmann, Desiderata, Copyright 1952.