Category Archives: culture

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??