Category Archives: physician

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.