Synthesis and Integration: Self and Other Focus

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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

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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

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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

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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.

 

 

Living Large in Seventh Grade

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NaBloPoMo 2018: What I’m Learning

Did you know that Abraham Maslow never represented his hierarchy of needs as a pyramid?  I didn’t either!  To be clear, I have not read the paper I just linked; it was linked in a different article I read today, describing more about Maslow’s work than I have ever known before.  It’s in Scientific American, entitled, “What Does It Mean to be Self-Actualized in the 21st Century?” by Scott Barry Kaufman.

Especially later in his life, Maslow’s focus was much more on the paradoxical connections between self-actualization and self-transcendence, and the distinction between defense vs. growth motivation. Maslow’s emphasis was less on a rigid hierarchy of needs, and more on the notion that self-actualized people are motivated by health, growth, wholeness, integration, humanitarian purpose, and the “real problems of life.”

I was intrigued by this piece because I remember so clearly when I first learned about Maslow’s Hierarchy.  It was in seventh grade, and I can’t remember anymore the class or context.  I just recall that it made so much sense, and I felt such a swell of joy at the possibility that something so complex could be distilled and explained so simply.  It would have been fair to predict at that time that I would go on to become a psychologist.  The boy I had a crush on that year (and all through high school, actually) asked me where I saw myself on the pyramid.  I remember looking at the tiers and thinking, very clearly, oh, I’m at the top.  I felt a little sheepish, afraid I would be seen as bragging, but it was the honest answer, and I said so.  “Bullshit,” was his reply.  I can’t remember our verbal exchange thereafter, but I think I was able to convince him that I really felt like I was ‘there.’  And I left that encounter feeling both a bit more self-aware and also proud that I had stood my ground and defended a truth.  You could also have guessed I would later entertain a brief interest in law school.

Kaufman has revisited Maslow’s work, including his hierarchy of needs, and evaluated the components in the context of modern life.  Reassuringly, 10 of 17 of Maslow’s self-actualization characteristics still stand up to ‘scientific scrutiny,’ (not sure how he measured this).  He names the ten characteristics in the article, and you can ‘take the quiz’ to see how self-actualized you are today.  I love quizzes like this.  I have done the Myers-Briggs at least 5 times.  Others I love are Gregorc Mind Styles, Insights Discovery, and the Gallup Strengths Finder.  The most useful ones tell you what you already know about your strengths, and also offer advice and insights on how to manage your blind spots.

But the most interesting aspect of Kaufman’s article to me was Maslow’s interest in self-actualization and its relationship to self-transcendence.  We can understand self-actualization as ‘achieving one’s full potential’ and self-transcendence as ‘decreased self-salience and increased feelings of connectedness,’ (again, not read the paper; it’s linked in Kaufman’s article) or basically subsuming and/or integrating oneself within a greater whole.  At first you may think that these are mutually exclusive states of mind and being.  The coolest thing is that it’s not actually an either/or proposition; it is absolutely both/and:

While self-actualization showed zero relationship to decreased self-salience, self-actualization did show a strong positive correlation with increased feelings of oneness with the world.

Self-actualized people don’t sacrifice their potentialities in the service of others; rather, they use their full powers in the service of others (important distinction). You don’t have to choose either self-actualization or self-transcendence– the combination of both is essential to living a full and meaningful existence.

It reminds me of another subsection of Chapter 3 in Leading Change in Healthcare, wherein Suchman et al discuss holding the tension and balance between self-differentiation (clear sense of individuality) and attunement (deep awareness and acceptance of how we are connected and resonant with those around us).  It also reminds me of Brené Brown’s work on trust; she describes eloquently in Rising Strong how we can neither trust others nor be trustworthy ourselves without clarity and boundaries around who we are and our core values, and living in that integrity all of the time.

Once again, I find encouraging and validating evidence for something I really feel I have known since an early age:  We are all our best selves and our best communities not in competition, but in collaboration.   Cohesion in diversity weaves a stronger social fabric of connections, more flexible and elastic.  But that means we need to know exactly what we as individuals each bring to contribute.  Personal, intrinsic meaning and purpose are foundational for substantive interactions with others and resilient communal relationships.

Our world can meet each and every one of our physiologic, psychologic, and self-fulfillment needs—we can provide this for one another.  We can each strive for our own goals, alongside our peers, and still help each other on the rocky, uphill parts.  We really need to stop with the scarcity thinking and get on with the business of working together, maximizing each of our strengths, and making society better for all of us.

Onward.

Fear, Ego, and Control

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NaBloPoMo 2018:  What I’m Learning

In this post I will attempt to describe some exciting connections between readings from the Harvard Business Review, Dr. Anthony Suchman and colleagues, and Carol Dweck.

An HBR article landed in my inbox this week, catching my inner Imposter’s attention.  The title, “Ego is the Enemy of Good Leadership,” triggered my ‘Is that me?’ reflex.  Because much of the time, I think I’m a pretty good leader (“I’m awesome”).  But I’m forever fearful that my ego will get the best of me and make me exactly the kind of leader I loathe (“I suck”).  I saved the article to read later.

Meanwhile, I continued to Chapter 3 of Leading Change in Healthcare: Authentic, Affirmative, and Courageous Presence.  Basically this chapter deals with earning and building trust.  Chapter subsections include self-awareness, reflection, emotional self-management, clarifying one’s core beliefs, and accepting oneself and others.  In the part on core beliefs, the authors reference Dr. Suchman’s 2006 paper, “Control and relation: two foundational values and their consequences.”  In it, he differentiates between these two ‘foundational world views’:

Control

The beliefs, thoughts and behaviors of the control paradigm are organized around a single core value: that the ultimate state to which one can aspire is one of perfect willfulness and predictability. What one desires happens, with no surprises; all outcomes are intended. For the clinician, the control paradigm is expressed in the questions, ‘‘What do I want to happen here?’’ and ‘‘What’s wrong and how do I fix it?’’  Personal success or failure is judged by the clinical outcome, the extent to which one’s intended outcome was realized.

Relation

In the relation paradigm, the most valued state to which one aspires is one of connection and belonging. In this state, one has a feeling of being part of a larger whole – a team, a learning group, a dance troupe, a community, even the world itself. One’s individual actions seem spontaneously integrated with those of others to a remarkable degree, contributing to the evolution of a higher order process, i.e. one at a higher system level than that of the individuals of which it is comprised…  One asks the question, ‘‘What’s trying to happen here?’’ and, according to one’s best approximation of an answer, seeks to shape others and the world while also remaining open to being shaped oneself. This balance between control and receptivity puts one in the best possible position to recognize and make use of serendipitous events.

In Leading Change the authors write about control, “…This is a fear-based paradigm in which one trusts oneself more than others and holds tightly to power…  It predisposes leaders toward dominance, distracts them from cultivating relationships and leads them to set unrealistic expectations of control.”  And about relation, “This is a trust-based paradigm, anchored in the belief that the sources of order, goodness and meaning lie beyond one’s own creation…  It predisposes leaders to do their best in partnership with others, to attend to the process of relating and to personal experience (their own and others’) and to remain open to possibility.”

When I finally read the HBR article, the message about ego reflected the control paradigm:

Because our ego craves positive attention… when we’re a victim of our own need to be seen as great, we end up being led into making decisions that may be detrimental to ourselves, our people, and our organization.

When we believe we’re the sole architects of our success, we tend to be ruder, more selfish, and more likely to interrupt others. This is especially true in the face of setbacks and criticism. In this way, an inflated ego prevents us from learning from our mistakes and creates a defensive wall that makes it difficult to appreciate the rich lessons we glean from failure.

The ego always looks for information that confirms what it wants to believe [confirmation bias].  Because of this, we lose perspective and end up in a leadership bubble where we only see and hear what we want to. As a result, we lose touch with the people we lead, the culture we are a part of, and ultimately our clients and stakeholders.

Going to bed last night, I wondered, “Is Fear actually driving when we see Ego in charge?”  I think the answer is undoubtedly yes, but it’s more complex than that.  It’s not a fear that we feel consciously, or that we are even aware of.  It’s not sweaty palm, palpitative, panic attack fear.  Rather it’s a deep, visceral, existential fear—of being found out, of not being enough—akin to imposter syndrome, if not exactly that.  Control, Fear, Ego—they all seem lump-able with/in the Fixed mindset, as described by Carol Dweck.  The simplest example of this mindset is when we tell kids how smart they are, they then develop a need to appear smart, lest they lose their identifying label.  So they stop taking risks, trying new things, risking failure.  Their experiences narrow as they, often inadvertently, learn that control of outcome and outward appearance of competence is the primary objective of any endeavor.

Back in August I listened to Dweck’s book, having heard about it and already embraced its theory in the last few years.  I had already started making the connection between fear and fixed mindset, but this day I saw a sudden, reciprocal relationship between fixed mindset, confirmation bias, and imposter syndrome.  I love when these lightning bolt moments happen—I was in my car on the way to work, and this triad came to me.  As soon as I parked and turned off the engine I tore into my bag for the journal I carry with me everywhere and scrawled the diagram as fast as I could, as if the idea would evaporate if I didn’t get it down in ink.  Later I added the comparison to Growth mindset—holding space for learning, integration, and possibility.  I held it in mind for a while, and then forgot it (which is okay—that’s why I wrote it down!).  Then today, putting together this post in my head, I remembered it with excitement.

8-31 triad update

The point of it all is that we are at our best, both individually and as groups, when we are in right relationship with ourselves and one another.  It all starts with relationship with self.  If I live in fear of being found out as flawed or imperfect, then I project that fear onto others.  I act out in an effort to control how others perceive me—when in reality I have no control over that whatsoever.  The negative perception of my ‘Ego’ by others then provokes myriad responses including fear, insecurity, false deference, resentment, disloyalty, and subversion, and the team falls into disarray.  If, on the other hand, I cultivate self-love and connection with others, I never feel that I am going it alone.  I am an integral member of a high-functioning, mutually respectful team, one in which I can admit my weaknesses and maximize my strengths.  We all feel confident that we can handle whatever adversity comes our way, and we rise to each and every occasion–together.

I’m still putting it all together, working out how it translates into daily behaviors, actions, and decisions.  For now I’m definitely paying closer attention to my feelings, especially in conflict, and taking a lot more deep breaths before speaking or replying to triggering emails.  I ask a lot more clarifying questions.  I try to make the most generous assumptions about people’s intentions, and remember always that we are on the same team—Team Humanity.

More learning happening around the clock, I say!  Hoping to articulate better in the sharing hereafter…

What do you think about all of this, does it make any sense at all??

Humanity

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NaBloPoMo 2018: What I’m Learning

I have festered all day drafting this post in my head.  Procrastinating.  It’s still a jumble, so I’ll give it my best shot:

Donald Trump is a human being.  As much as I want to hurl epithets and lob rotten tomatoes at the television every time his face appears, or take a sledgehammer to whatever device I hear his voice on, I know these are unproductive responses to the emotions he triggers in me.  Breathe.  Must. Do. Better.

Ever since the 2016 campaign started in June of 2015, three and a half years ago already, I have felt an almost daily rage like nothing in my life yet.  I’m happy in some ways to report that it has not improved—I have not normalized this aberrancy of an administration.  But the constant animosity is not good for my health.  And the escalating divisions and vitriol between various groups of people, ever more visible on phone cameras and instant video, erodes our humanity every day.  I think I’m also increasingly sensitive to it all now.  On one hand I’m glad because awareness of humanity, and opposing those who diminish it, is good.  But again, it costs me.

Donald Trump is the personification of dehumanization (oh, the irony).  Some may feel this is an exaggeration, too strong a word to use.  It is not.  He is a hardened master of this insidious craft, and we are each capable of the same, whether we admit it or not.  It starts with making people abstractions—by seeing them, even very subtly, as less than whole people with feelings and needs equally important as our own.  Simon Sinek discusses it eloquently in his book Leaders Eat Last; you can read an iteration of his thoughts in this interview.  He describes CEOs like Jim Sinegal and Bob Chapman who, in hard times, gave employees raises and decreased workers’ hours, respectively, rather than laying anyone off.  I learned during a lecture, though I cannot find the citation (Boehm, 2015?) that only 17% of healthcare CEOs take the well-being of their employees into account when making decisions.  Sinegal and Chapman sacrificed some numbers to save people, Sinek says.  Too many leaders sacrifice people to save the numbers.  Turning people into abstractions is both akin to and a step toward dehumanizing them.

I have a friend who used to criticize people, ideas, or things by saying, “That’s (he’s) so gay.”  He would deny his negative attitude, deny that he was using ‘gay’ as a derogatory term.  He would also deny that he was biased against homosexuals.  I believe he would never treat anyone badly because they were gay, let alone commit any kind of hate crime.  But ‘being gay’ was a negative abstraction to him.  It was abnormal, something to be derided and shamed—to be scorned.  His objection to the idea of homosexuality made homosexuals, as a group in his mind, less than.  I think we all do this more often than we know.  I wrote about it last year, describing how doctors in different medical specialties talk about each other in pejorative stereotypes.  We dehumanize each other every damn day.

Brené Brown describes this clearly in her book Braving the Wildnerness:

Dehumanization has fueled innumerable acts of violence, human rights violations, war crimes, and genocides. It makes slavery, torture, and human trafficking possible. Dehumanizing others is the process by which we become accepting of violations against human nature, the human spirit, and, for many of us, violations against the central tenets of our faith.

How does this happen? Maiese explains that most of us believe that people’s basic human rights should not be violated—that crimes like murder, rape, and torture are wrong. Successful dehumanizing, however, creates moral exclusion. Groups targeted based on their identity—gender, ideology, skin color, ethnicity, religion, age—are depicted as “less than” or criminal or even evil. The targeted group eventually falls out of the scope of who is naturally protected by our moral code. This is moral exclusion, and dehumanization is at its core.

Dehumanizing always starts with language, often followed by images. We see this throughout history. During the Holocaust, Nazis described Jews as Untermenschen—subhuman. They called Jews rats and depicted them as disease-carrying rodents in everything from military pamphlets to children’s books. Hutus involved in the Rwanda genocide called Tutsis cockroaches. Indigenous people are often referred to as savages. Serbs called Bosnians aliens. Slave owners throughout history considered slaves subhuman animals.

Again, you may think that I over-exaggerate here.  What’s the big deal, you say, when surgeons say internists wear flea collars (stethoscopes)?  Or when Trump calls Mexicans criminals and rapists?  When he calls women dogs, Miss Piggy, and Horseface, you say, it has no real effect.  Sociology begs to differ.  It is a slippery slope from thoughts to words to action, and Donald Trump has poured oil on the Slip ‘n’ Slide by the bucketful.  Don’t believe me?  How else could we countenance forcibly separating toddlers from their parents when they arrive on our doorstep, fleeing violence and seeking asylum, sending the children across our country and deporting the parents, with no intention of ever reuniting them?  If that’s not dehumanization I don’t know what is.

Once again, Brené Brown says it much better than I:

Today we are edging closer and closer to a world where political and ideological discourse has become an exercise in dehumanization. And social media are the primary platforms for our dehumanizing behavior. On Twitter and Facebook we can rapidly push the people with whom we disagree into the dangerous territory of moral exclusion, with little to no accountability, and often in complete anonymity.

Here’s what I believe:

  1. When the president of the United States calls immigrants animals or talks about grabbing pussy, we should get chills down our spine and resistance flowing through our veins. When people call the president of the United States a pig, we should reject that language regardless of our politics and demand discourse that doesn’t make people subhuman.
  2. If you are offended or hurt when you hear Hillary Clinton or Maxine Waters called bitch, whore, or the c-word, you should be equally offended and hurt when you hear those same words used to describe Ivanka Trump, Kellyanne Conway, or Theresa May.
  3. If you’re offended by a meme of Trump Photoshopped to look like Hitler, then you shouldn’t have Obama Photoshopped to look like the Joker on your Facebook feed.
  4. When we hear people referred to as animals or aliens, we should immediately wonder, “Is this an attempt to reduce someone’s humanity so we can get away with hurting them or denying them basic human rights?”

When we engage in dehumanizing rhetoric or promote dehumanizing images, we diminish our own humanity in the process. When we reduce immigrants to animals… it says nothing at all about the people we’re attacking. It does, however, say volumes about who we are and our integrity.

Dehumanizing and holding people accountable are mutually exclusive. Humiliation and dehumanizing are not accountability or social justice tools, they’re emotional off-loading at best, emotional self-indulgence at worst. And if our faith asks us to find the face of God in everyone we meet, that should include the politicians, media, and strangers on Twitter with whom we most violently disagree. When we desecrate their divinity, we desecrate our own, and we betray our humanity.

So I resolve to stop participating in the erosion of humanity.  When I hear dehumanizing language from anywhere, especially among my own tribes, I must resist the urge to respond in kind.  I will look for opportunities to call it out.  It is so damn hard, I feel so often like a pressure cooker waiting for the valve to release.  So I must practice patience, kindness, mindfulness, deep breathing, and all of the habits I reviewed here yesterday.  I must find it in myself to always hold another’s humanity as sacred as my own, even (especially?) the people I despise the most.  It will be a lifelong exercise in discipline and agape love.  As the Obamas teach us, we must stay Fired Up, Go High, and Be the Change.  I can do this.  Donald Trump is a human being.