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??

Hope You’re Safe in Chicago

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NaBloPoMo 2018:  What I’m Learning

My friend texted me these words at 4:01pm Central Standard Time today.

Tamara O’Neal, an emergency medicine physician just one year out of training, was shot to death by her ex-fiancé.  He then went on to kill two others, and he himself died, though it remains unclear if he shot himself or died from a police officer’s bullet.  She was on her way to work, saving lives for a living, many of them probably victims of gun violence.

Samuel Jimenez, a 28 year-old police officer, also only beginning his career, was killed.  He leaves behind a wife and three young children.  He was doing his job, protecting innocent lives from deadly violence.

Dayna Less, a 25 year-old pharmacy resident, was also killed.  She was still in training, planning to go home to Indiana tomorrow to celebrate Thanksgiving with her family, and planning a wedding next year.

It could have been my hospital, or my husband’s hospital.  Or one of the hospitals where my sister or my friends or my mom work.  It could have been my children’s school.  An elementary school a few blocks away was locked down until 5pm.  What must that have been like for the kids and their parents?

I was safe in Chicago—today.  But none of us are actually safe, as long as we collectively continue to do nothing about the public health crisis of gun violence that grips and gags us.  And make no mistake it is a public health issue before it is a political issue.  That said, we in healthcare must continue rise up and call for action in policy.  We must demand more of our elected officials.  They must represent us and our collective public interest first and foremost.  A majority of the American public supports common sense gun laws like background checks, licenses for gun dealers, and restricting gun ownership by known domestic abusers.  This should be reflected in our laws and law enforcement.

Please read about the victims of today’s shooting.  Remember them before you read about tomorrow’s victims.  Look up the people who died in Parkland and Pittsburgh.  Put yourself in their shoes, as events unfolded on what started as just another day in their lives.  Imagine what must have flown through their minds—thoughts of children, parents, spouses, regrets, things they wish they had done, things they had looked forward to.  Imagine the terror, the disbelief, the pain, the utter loneliness, the longing for the comfort of loved ones, the wish for another day to be with them, to say goodbye.

Imagine being their family members now, trudging on each day without them, senselessly, with no justice, no closure.  Imagine caring for patients and their families in the emergency department, the intensive care unit, the neurological rehab hospital.  Imagine looking into the eyes of these people, the remaining years and decades of their lives irrevocably altered for the worse by events that unfolded over a few minutes.  And then imagine, as you continue to gaze into their eyes, telling them sorry, there’s nothing we can do about it, this is just the way it is.

The only way enough of us will be moved to take action is if enough of us can truly relate to the experiences of the victims and their families.  Nobody needs to actually live through such horror to be able to empathize.  The human brain is wired for empathy and connection.  At the same time that we cannot imagine what it must be like, we can absolutely imagine.  But we choose to separate, to disconnect, when things are too uncomfortable, to protect ourselves.  This is how tragedies like Columbine continue to happen, every week, every year, for decades.  Not. Acceptable.

Read the American College of Physicians position paper on reducing firearm injuries and deaths.  Apply a critical and objective eye and mind.  Try to understand its reasoning and look up the citations.  Read the appendix, the expanded background and rationale.

Do you want fewer people to die from gun violence in the United States?

What will you do to help reduce the harm?  Because we all need to help.

 

 

 

 

 

Culture of Medicine, Part II

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NaBloPoMo 2018:  What I’m Learning

So, what did you think of how trainees described the Culture of Medicine?  If you’re in medicine, how much did you resonate?  If you’re not in medicine, how much were you surprised, or not?  How do you think this affects our relationships with you, our patients?

Do you wonder how we get through any given day?

I asked the group:  What are characteristics or traits of Culture of Wellness (COW) Leaders?  Once again, I present their responses here, in order of discussion.

  1. “They ask how people are doing.” They are proactive about it, opening the door, making it safe to talk honestly about how we really are doing.  They exhibit the ‘body language of listening.’  It’s still hard to talk about it, one student pointed out.  The best leaders explicitly carve out time to talk, to invite feedback.  It also matters what they do with the information once they get it—empathizing and acting on it if needed, rather than dismissing.
  2. Mentor. This is someone who knows you and whose role it is to help you ‘unconditionally,’ different from any of your evaluators—maybe an advisor.  It can be an informal relationship, maybe just someone you want to emulate.  Trainees agreed that it often happens organically, and they seek it actively.  One resident identified her program director as ‘absolutely a COW leader.’
  3. Walk the Talk. Examples: work/life balance/integration, acceptance of mistakes, admitting when you don’t know something.  NO DEFLECTING; OWN YOUR SHIT.  This one hit home with me—this is Integrity.  As Brené Brown says, integrity is “choosing what’s right instead of what’s fun, fast, or easy.  It is living your values rather than simply professing them.”

The next several descriptors emerged in a flurry.  The atmosphere in the room swelled with positive energy as one label after another of what we admire about our teachers and colleagues overtook the downtrodden mood just moments before:

  • Consistency
  • Proactivity
  • Openness
  • Empathy
  • Personally engaged
  • Curiosity
  • Caring
  • Kindness
  • Vulnerability—willing to share
  • Positivity—seeing mistakes as learning opportunities. Encouraging—“We’ got this!”
  • (Understand the importance of) Food: attending to physical needs
  • Humor—acknowledging the challenge and weight of the work and also holding it loosely
  • Validating
  • Appreciative
  • Grateful

The last one triggered a story.  One student rotated on an inpatient service.  Critically ill patients poured into the hospital; all work hour restrictions were necessarily violated.  Nerves were more than frayed, and people were at their worst.  He witnessed open hostility by senior residents toward interns, backstabbing, undermining.  The attending, present only minimally, was oblivious.  And, “They never said thank you.”  The student, who had planned to enter this field, considered switching.  It was that bad.  But somehow, he was able to get perspective and remind himself that this one bad experience did not represent the whole of this specialty.  It had been an unusually busy month at the end of a long, hard year.  Maybe the cumulative exposure to some of his COWL role model traits had rubbed off, and buoyed him when he stepped onto a leaky boat.

A senior student admitted that when she started medical school she had heard of burnout.  “I initially didn’t believe it could happen to me…  Then later I realized it can happen to anybody—it could absolutely be me, if I don’t take care of myself.”  I asked what that means, taking care of yourself?  They answered:

  • Sleep
  • Nutrition: “Any food your intern year; choices matter more when you’re PGY (post graduate year) 3!”
  • Outside interests
  • Finding a practice situation that fits: eg caring for the underserved, women’s health, hospital medicine, etc.
  • Find Your Tribe. The trainees did not use these words, but this is what I wrote in my notes—they expressed a need for belonging.
  • People at work: truly collegial relationships, especially across specialties
  • Confidants: safe people to share with, your emotional support network
  • Physician-Patient relationships: mutually vulnerable and open

I asked them what they needed to take care of themselves.

  1. Purpose
  2. Time—to be given by the system, and also to be responsible and efficient with themselves.
  3. Habits—established and also adaptible

Overall the discussion felt productive and successful in the end.  We had just mapped out the way(s) to Be The Change we seek in our profession.  Some of them took pictures of my notes (so Millennial), which made me feel gratifyingly connected.  I had tried to question more than lecture, to explore and facilitate more than ‘teach.’  I wanted each of them to own their own path to leading from any chair, now and forever.  I proposed that they could start the moment they walked out of the conference room door—no elevated status or title necessary.

This is why the calling still resounds compellingly, why our enthusiasm for the work persists resolutely, despite the hardships.  It’s Hope.  And at its foundation lies the bedrock of our best relationships—with ourselves, with one another, and with our patients.  On the march toward a true Culture of Wellness, real leaders go in front and set the example.  The rest of us learn by mimicking.  Thus we all have leadership potential and, dare I say, responsibility.  We are the system; we make the culture—each and every one of us makes a unique contribution.  Nothing we do is too small to matter.

Onward.

Culture of Medicine, Part I

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NaBloPoMo 2018:  What I’m Learning

Recently I met with a group of medical trainees from different institutions, ranging from pre-med to senior resident.  The topic was leadership in medicine and culture.  My objective was to lead a discussion on how we see leadership, and to encourage physicians at all levels of training to see themselves as leaders, regardless of designated status.  I often invoke Benjamin Zander’s invitation to ‘lead from any chair.’

We started out discussing the current state of medical culture.  My summary of the labels, in the order we discussed them, follows here.  I strive to hold these observations with minimal judgment, and to practice radical acceptance.  This is simply the way things are, not good or bad, it just is.  That includes how we feel about it all, and that we want to change the parts we don’t like.  Tomorrow I will continue with Part II, characteristics of Culture of Wellness leaders.  For now I invite you, especially my friends in medicine and healthcare, to review the list dispassionately, objectively, from a distance.  See how it lands.  How do you feel reading this list?

  1. Intense
  2. High stakes—we hold people’s lives in our hands.
  3. Imbalanced. When asked to say more, this trainees explained, “It encourages a lack of balance—we are not supposed to mind the long hours.  Our priorities are skewed—we say patients first (but it feels like patients above all else, at any cost?).  There’s the paperwork, the burnout.  You can’t go home if the patient needs you (internal medicine), and in some fields there is no such thing as a shift.  It never ends. (surgery)”  These trainees felt no work-life balance.
  4. Resistant to change. It’s an attitude—“When I was your age…”  Anything different and new in terms of work hours, work load, etc. is deemed bad or inferior before it’s even considered.
  5. Hostile. Between staff members, between doctors and nurses, between doctors themselves, nurses themselves.  The trainees saw this as a key contributor to everybody’s burnout.
  6. Hierarchical—especially surgery (they pointed this out explicitly). For example, walking in the halls, there is an order in which people enter patient or operating rooms.  One student reported entering before her team, because she knew the patient, and making small talk.  Later, she reported, “the senior resident yelled at me, said to go in order, and do not talk to the patient.  In 2017.”  In the OR, when students cut sutures, they must always cut the attending’s suture first.  One medical student was admonished loudly in the OR for this.
  7. “You’re expected to know everything already, even though you’re supposed to be learning on the job.” Trainees agreed that they expect to have to prepare for each day at work.  But as trainees, they cannot always know how to prioritize information as they study in advance for what feels like daily examination.  And they are belittled and shamed for not reading their instructors’ minds and knowing exactly what the teacher is asking for (‘pimping’ the students, as it’s known).  “I never feel like enough.”

At this point you may suspect that I somehow planted the seeds of negativity in these trainees’ minds, goaded them on to blast our profession and everybody who had ever said something mean to them in the hospital.  I assure you I did not, and I marveled myself at how easily these labels flew onto the table.  I hurried to take notes.

Thankfully the vibe circled, as it often does.  One woman commented:

  1. “Family medicine seems actually anti-hierarchy.” Attendings, she observed, often defer to students, who usually know the patients the best, when discussing patient history and data.  Team members may all address one another by first names.  Another student piped in:
  2. Pediatrics is similar. Attendings cover for the team during signout, answering pages and signing orders—everybody pitches in.    On rounds students are allowed to be students—to make mistakes, to show gaps in knowledge.  And a resident pointed out:
  3. In anesthesia, team members take breaks, and she felt a sense of autonomy and support of residents—no shaming. “Maybe it’s the nature of the work,” she said, “it’s easier to tag team.”

Fascinating.  I was practically trembling with excitement—here were ten strangers, from different specialties and at various levels of training, men, women, people of diverse colors and cultures.  And we all had the same experience of our chosen profession, much of it negative.  Yet here we all were, committed and still excited to be doing this work—we all still hear the call.  Whatever keeps us going?  How do we get up every morning and come to work in this ‘toxic’ environment?

I’ll tell you tomorrow.

Frass, Trauma, and Other Stuff

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NaBloPoMo 2018:  What I’m Learning

Can’t think of anything useful to write today…  Or rather, I’m too tired to make any half useful thoughts into enough coherently connected sentences to be worth publishing.

So I’ll share some small things I have learned recently, which I find interesting.

Frass

Noun.  Fine powdery refuse or fragile perforated wood produced by the activity of boring insects.  The excrement of insect larvae.

I have a wonderfully smart and kind friend who conserves paper for a living.  Do you know any expert paper conservators up close and personal?  If so then you know the exquisite mind and temperament it takes to do this work.  She must possess the exacting scientific leanings that comprehend both biology and advanced chemistry (inorganic and organic).  She holds the vast sweep of art history, especially as it applies to paper and ink as media, at her fingertips.  And her appreciation for the uniqueness and intrinsic value of every piece drives her pursuit of the end product.  She must command all of this knowledge in an integrated fashion, bringing to each new project confidence, curiosity, and love.  And when she works on an old map in the library archives caked with dust and soot, and tells her friend about the project, she teaches her friend the word frass.

Getting out tree sap and other cool tips

You probably already know about using Coca-Cola to clean toilets, and salsa or ketchup to shine pennies and silver.  But did you know that olive oil and butter get out tree sap, and mayonnaise gets off glue residue?  Unbrewed coffee grounds absorb mildew if you leave them in an open container at the bottom of a closet for several days.  Vodka works well for getting smells out of clothes.  And rubbing your hands with salt can get out the smell of onion or garlic.

Toxic gaslighting

I only learned the word ‘gaslighting’ after the 2016 election.  *sigh*

The word was among the final contenders, apparently, for the Oxford English Dictionary’s 2018 Word of the Year.  But ‘toxic’ won.  Says the head of the company’s US dictionaries, “the word was chosen less for statistical reasons… than for the sheer variety of contexts in which it has proliferated, from conversations about environmental poisons to laments about today’s poisonous political discourse to the #MeToo movement, with its calling out of ‘toxic masculinity.’”  Last year’s WotY was ‘youthquake.’

Trauma

Last weekend I spent time with a wonderful residency classmate and her amazing family.  She is the Chief Medical Officer of a large health system that serves a population with a high prevalence of mental illness and substance abuse.  I got to hear about her passionate and profoundly important work educating and advocating for trauma-informed care, which I am only starting to learn about.  Interestingly, NPR had just posted an article detailing findings of a study published in the Journal of the American Medical Association (JAMA) showing that childhood trauma is strongly associated with poor adult function outcomes, such as mental illness, failure to hold a job, and social isolation.  By age 16, 31% of children in the study had had one traumatic exposure, 22.5% had had two, and 14.8% had had three.  What does that look like at the doctor’s office?  Read the Harvard story of the two kids and their vaccines here.  What can we do about it, as physicians and society?  First, recognize the prevalence.  NPR asked, “Should childhood trauma be treated as a public health crisis?”  The answer, unequivocally, is yes.  Second and always, practice curiosity and empathy. Every day.  All the time.  Again and again.  If someone is acting out, before judging them for being difficult and ruining your day on purpose, ask what could lie behind the behavior.  Everybody deserves and benefits from a little concern and gentleness. And if you’re a healthcare professional, start with the Harvard article, and then read this one from the National Council for Behavioral Health.  We all need to treat each other better.  So much better.  Please.

So, what interesting thing(s) have you learned lately?

Less Phone, More BOOKS!

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NaBloPoMo 2018: What I’m Learning

Hi, I’m Cathy, and I’m addicted to my phone.

Last month I finally decided to do something about it, mostly so I could be more present to the kids.  It’s been a fascinating journey so far, and I’m proud to say I’ve already made progress.  First I banned Facebook after 6pm.  That went well until I traveled.  Then I took the Facebook app off of my phone.  The withdrawl continues to spike at times.  I also notice that I use other things to substitute—New York Times, email, Washington Post, email, WordPress Reader, email.  I notice an anxiety, a frustration, a kind of crazed, darting hankering– I crave that dopamine hit.

The awareness of it all, however, and the commitment to get disentangled from my screen, has cleared space for a recently dormant impulse to surface afresh:

READ!

* * *

At the conference last month I was turned on to the idea of complexity (or chaos) theory and how it relates to fixing physician burnout and turning our whole medical system around.  It was positively mind-blowing (for me—most others did not seem quite as lit).  The speaker was Anthony Suchman, my newest hero.  Some highlight ideas:

  • Every system is perfectly designed to get exactly the results it gets. Our current healthcare system evolved to this point precisely from serial and cumulative decisions made over years, even though the current state was never the intent.
  • We think of organizations as machines, with predictable, linear consequences of adjustments in one part or another. This is rarely how organizations (of people) actually work.  Rather, we can think of organizations as conversations, and let go our expectations of particular outcomes, the illusion of total control.  We can let things unfold and go where the outcomes lead us, all while holding to core values and goals.
  • Patterns are (re)created in each moment, and also self-organizing. So at the same time that a pattern (eg culture) seems inevitable and self-propagating, sometimes small, almost imperceptible perturbations can create new and dramatic cascades that lead to transformation (the butterfly effect).
  • Emergent Design thus embraces the approach of “finding answers we are willing to not know,” trusting that we will get where we need to go simply because we are paying attention (or that’s how I interpret it today).

This theory that everything within a system both results from and also contributes to the whole system (a fractal) validates an idea I have been advocating to my patients for years, and that I continue to personally relearn ad nauseam: It’s all connected.  The most concrete examples are Sleep, Exercise, Nutrition, Stress Management, and Relationships—I used to call them the 5 Realms of Health; now I call them the 5 Reciprocal Domains.  Each one is inextricably connected to every other one, and they all move in concert, with subtle or dramatic dynamics.

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I browsed around my local bookstore a couple weeks ago and came across a colorful title on the shelf: Emergent Strategy by Adrienne Maree Brown.  So of course I snatched it up.  The blurb says:

Inspired by Octavia Butler’s explorations of our human relationship to change, Emergent Strategy is radical self-help, society-help, and planet-help designed to shape the futures we want to live.  Change is constant.  The world is in a continual state of flux.  It is a stream of ever-mutating, emergent patterns.  Rather than steel ourselves against such change, this book invites us to feel, map, assess, and learn from the swirling patterns around us in order to better understand and influence them as they happen.  This is a resolutely materialist “spirituality” based equally on science and science fiction, a visionary incantation to transform that which ultimately transforms us.

Holy cow, YAAAAS!!  I could not wait to read it!  So I bought it, along with Make Trouble by Cecile Richards, What If This Were Enough? By Heather Havrilesky, and The Dharma of “The Princess Bride” by Ethan Nichtern.  I had also ordered Leading Change in Healthcare, coauthored by Dr. Suchman and two others.  That copy arrived last week.

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I feel this as all part of a slow turn, getting off my phone and diving into books again.  I’m so excited.  I have done this before—buy a bunch of books and never read them.  They occupy whole shelves in my bedroom.  But I honestly feel a transformation coming on.  Yesterday I spent a couple hours reading, researching, and writing the blog post, then I turned off the computer and opened Brown’s book.  I read through the long introduction and resonated with sentences like, “Emergence is the way complex systems and patterns arise out of a multiplicity of relatively simple interactions.”  This is a quote from Complex Adaptive Leadership: Embracing Paradox and Uncertainty by Nick Obolensky (which I have also now ordered).  I also love (ha!), “Perhaps humans’ core function is love.  Love leads us to observe in a much deeper way than any other emotion.”  Also:

all that you touch

you change

all that you change

changes you

the only lasting truth

is change

god is change

That is a quote from Parable of the Sower by Octavia Butler.

Then before bed I opened Suchman et al’s book and found these words, also in the introduction:

Complexity theory here is enriched by the focus on relationships [Hallelujah!], rather than the more traditional reference to science.  “Relationship-Centered Care” is a way of thinking that brings love and all that is personal into a world, the world of healthcare, that is mostly interested in more control and more data-based, evidence-based practices.

The point is made throughout that administrators cannot bring real change into their healthcare institutions without going through change themselves.

(The book describes) the relationship-centered social dynamics that are at the heart of Lean and a major source of this method’s success.  Unfortunately, these social dynamics are overshadowed or even displaced by the analytic technique in some Lean implementations, compromising results.

Suchman 2

So I’m learning about new ways to think on change.   It’s changing how I approach trying to change my patterns, how I see my relationship to them, how I see all relationships.  Wow.

All of this to say, I feel a deeply personal, yet global and cosmic impulse for growth, for transformation—a shift into more mindful and intentional use of my time and energy, and how I manifest it outward.  Less distraction, more focus.  Less incidental information consumption, more integrated learning and coordinated application.  Less phone, more BOOKS.

What will be the outcome?  I have no idea, that’s what makes it so exciting and wonderful!  Onward!

 

How Not to Engage

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NaBloPoMo 2018: What I’m Learning

My friend Alex* posted about being a nurse and how she loves it despite having to always hold her pee, skip lunch, and get bled on, puked on, peed on, and yelled at, all while missing her family and taking care of yours.  One of her friends, we will call him Greg, commented that until nurses unionize and demand professional respect ‘just like physicians,’ nothing will change.

My impulsive (GRRR!) response:  “Trust me, physicians are struggling, too. I propose that we stand up for one another. Then we’d really be a strong force. And in the end it benefits us all–doctors, nurses, patients, the whole care team and, most importantly, patients. Also, I don’t know of any unions that physicians can join, but there are ones that nurses can: https://nurse.org/articles/pros-and-cons-nursing-unions/”  Okay, I know, saying, “Trust me,” is not a good way to get someone to trust or listen to you.  And my reply was defensive in its origin.  I sincerely believe what I wrote, though, that allied advocacy is an untapped force for good in medicine.  Physicians, patients, nurses, all healthcare professionals—why should we not actively support one another in all of our efforts to achieve a more cohesive, efficient, fair, and collaborative system, one that works better for all of us?  Why can we not embrace our connections and combine our voices to call for change?

Greg replied that basically he does not believe that physicians are “struggling,” and he does not see how we would stand up for one another.  After Alex described that I’m a physician “who will always help the nurses,” he wrote that doctors “can’t be in the business of supporting nurses.”  That we should “be in the business of supporting” ourselves, and “from all the research I’ve ever seen, they’ve continued to do a pretty good job of it.  Good for them.”  He expressed support for physicians’ right to advocate for ourselves.  In each reply, he continued to make his point that nurses should unionize.

I find this thread fascinating.  There are so many ways Greg and I could interpret each other’s replies.  When he talks about demanding respect ‘like physicians’ through unions, what benefits and outcomes does he imagine will follow?  When I say “struggling,” I wonder what he thinks I mean?  Actually he asks me, “How exactly are physicians struggling?”  He goes on to write, “Nurses are nurses and should be for nurses.”  All of his comments and the tone I inferred from them caused me to beg off of the thread.  Too bad, it might have been an interesting conversation—if we could have it in person.  Maybe we can later.

But it motivated me to look up some information to post here, in case anybody wonders ‘how physicians are struggling.’  The answer is burnout, depression, suicide, and leaving work that we love because it simply costs us too much—and I mean costs other than money.

Physician burnout is well described and referenced.

Doctors suffer from burnout in especially high numbers, according to the study, which was designed to offer a representative snapshot of doctors and the general U.S. working population. Nearly half of U.S. physicians – 49 percent – meet the definition for overall burnout, compared with 28 percent of other U.S. workers. More than 54 percent of doctors have at least one symptom of burnout, a more detailed analysis found.

Doctors also register more than one and a half times the general working public’s rates of emotional exhaustion and depersonalization. Working a median 50 hours per week, their satisfaction with work-life balance is far lower than that of others: 36 percent versus 61 percent.

medscape burnout causes 2018

Medscape Survey 2018

There are myriad causes for physician burnout, and most of them lie in the system, not in our inherent lack of resilience or because of some intrinsic defect in our collective character.  The electronic health record has accelerated our dissatisfaction with work.  It does so by creating innumerable clicks to accomplish menial tasks, burdening us with data entry that detracts from actual medical decision making and patient care, and putting a physical barrier between us and our patients, further separating us in relationship.  Burned out and dissatisfied doctors are distracted, less empathetic, and aloof, and we may even make more mistakes.  And when we aren’t well, our patients aren’t well.

A 2015 Mayo Clinic study reported that roughly 40 percent of physicians suffer depression each year and almost 7 percent had considered suicide within the prior 12 months. It is estimated that 300 to 400 doctors take their lives every year.

The pain and suffering those statistics only hint at is bad enough. But they are compounded by findings that burnout corrodes the doctor-patient relationship, resulting in lower levels of patient satisfaction, job satisfaction and productivity, as well as higher levels of medical errors and disruptive behavior.

Burnout is also connected to the decision to switch jobs or leave medicine altogether — an ominous trend as the U.S. experiences a growing doctor shortage.

 

I have not addressed here the challenges that nurses face every day.  My mom is a nurse, and I have worked with nurses my whole career.  I see how they are treated by the system and by patients, and also by us physicians.  And yes, my extracurricular activities focus solely on advocating for physician health and well-being.  Maybe I should learn more about nurse burnout and job satisfaction, and figure out ways to advocate for my nursing friends and colleagues better.

Or maybe it’s too much to ask for groups to stick up for one another.  Maybe Greg is right, and it should be every tribe for itself, let others take care of their own.  Maybe it doesn’t do any good for people to know how and how much doctors “struggle.”  I don’t know.  But I have learned now not to instigate such debates on my friends’ pages on social media.

*Not her real name