Tag Archives: communication

Tribal Pride and Tribalism

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NaBloPoMo 2017: Field Notes from a Life in Medicine

What tribes do you belong to?  How do they serve you, and you them?  How not?

I think of this today as I have traveled out of state to speak to a Department of Surgery on physician well-being.  I wonder how often they have internists present at their Grand Rounds?  What a tremendous honor, I’m so excited to be here!  I hope my talk will be useful and memorable, as I represent my field and my institution, in addition to myself.  In the talk I describe the central tenets of Tribal Leadership and culture, and how to elevate ours in medicine.

So I’m thinking tonight about tribal pride and tribalism—the benefits and risks of belonging.

We all need our tribes.  Belonging is an essential human need. To fit in, feel understood and accepted, secure—these are necessary for whole person health.  And when our tribes have purpose beyond survival, provide meaning greater than simple self-preservation, our membership feels that much more valuable to us.  But what happens when tribes pit themselves against one another?  How are we all harmed when we veer from “We’re great!” toward “They suck”?

Of course I’m thinking now of intra-professional tribalism:  Surgery vs. Medicine vs. Anesthesia vs. OB/gyne vs. Psychiatry.  Each specialty has its culture and priorities, strengths and focus.  Ask any of us in public and we will extol each other’s virtues and profess how we are all needed and equally valuable.  Behind closed doors, though, internists will call orthopods dumb carpenters; surgeons describe internists’ stethoscopes as flea collars, and the list of pejoratives goes on.  Maybe I’m too cynical?  My interactions with colleagues in other fields are usually very professional and friendly—until they are not.  I have experienced condescension and outright hostility before.  But can I attribute it to tribalism—that general, abstracted “I’m better than you because of what I do” attitude—or to individual assholery?  Or maybe those docs are just burned out?  As with most things, it’s probably a combination.  Based on what my medical students tell me, negative energy between specialties definitely thrives in some corners of our profession.  Third year medical students are like foster children rotating between dysfunctional homes of the same extended family—hearing from each why all the others suck.

So what can we do about this?  Should we actively police people’s thoughts and words in their private moments?  I mean part of feeling “We’re Great!” kind of involves comparing ourselves with others and feeling better than, right?  Isn’t some level of competition good for driving innovation and excellence?  Should we even embrace this aspect of tribal pride?  It certainly does not appear to be diminishing, and I have a feeling it’s just human nature, so probably futile to fight it.

I wonder why we have this need to feel better than.  Is it fear?  A sense of scarcity?  As if there is not enough recognition to go around?  Like the pie of appreciation is finite, and if you get more I necessarily get less?  Intellectually we recognize that we are all needed, we all contribute.  But emotionally somehow we still feel this need to put down, have power over, stand in front.  And it’s not just in medicine.  I see it in men vs. women, doctors vs. nurses, liberals vs. conservatives, and between racial and ethnic groups.  It makes me tired.

But maybe we can manage it better.  Maybe we can be more open and honest about our tribal tensions, bring them into the light.  Yes, I think surgeons can be arrogant.  And that’s okay to a certain extent—it takes a certain level of egotism to cut into people, and when things start going wrong in the OR, I think that trait can help make surgeons decisive and appropriately commanding when necessary.  I imagine surgeons get impatient with all the talking we internists engage in.  So many words, so little action, they might think.  And yet they understand that words are how we communicate with patients, how we foster understanding and trust.  Maybe we can all do a better job of acknowledging one another’s strengths and contributions out loud and in front of our peers (and learners).  The more we say and hear such things, the more we internalize the ideals.

Tomorrow I get to spend a morning with surgical attendings and residents.  I hope to contribute to their learning during my hour long presentation, but I really look forward to my own learning, to expanding my understanding and exposure to parts of my profession that I don’t normally see.  I’m humbled at the opportunity, and I will look for more chances to bring together colleagues from divergent fields.  If we commit, we can connect our tribes and form a more cohesive profession.  That is my dream for future generations of doctors—to be freed from infighting and empowered to collaborate at the highest levels, for the benefit of us all.

 

I’m the Doctor, You’re the Doctor

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NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.

Hopey, Changey Hero Making

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IVY Litt 11-8-17

NaBloPoMo 2017: Field Notes from a Life in Medicine, Day 8

Funny how I just wrote last night about connecting new dots to old dots.  It just happened again tonight!  A couple of weeks ago I responded to an online ad for an IVY Ideas Night with David Litt, author of Thanks Obama: My Hopey, Changey White House Years, entitled, “How to Inspire, Persuade, and Entertain.”  Litt was a senior speechwriter for President Obama, so I thought I could learn new tips for presentations, and feel a little closer to the president whom I miss so much.

I’ve done public speaking since eighth grade, when our speech teacher first taught us abdominal breathing and I discovered the thrill of holding the attention of a room full of people with only my words.  I work at an academic medical center and I hold zero publications, but my CV documents over 10 years of professional presentations to various audiences.  I thought I was pretty good at this speaking thing.

Three years ago I came across this TED talk by Nancy Duarte, whose ‘secret structure’ of great presentations I have used since I subsequently read her book, Resonate.  Essentially, she recommends that we invite audiences on adventure stories, create active tension between what is and what could be, and most importantly, make the audience the hero.  I have done this better and worse since then, but I always recognize the framework when I see it.  Those familiar with this blog know that I am also a fan of Simon Sinek, whose central message is that we perform at our best when we are crystal clear about our Why.  “People don’t buy what you do, they buy Why you do it,” he says.  Barack Obama employs both authors’ principles with eloquence and finesse, which I noticed reading We Are The Change We Seek, a collection of his speeches as president.  The best speeches delivered in this construction create audiences who are inspired, motivated, and empowered to hail a meaningful call to action.

Obama is could be core values

That’s basically what David Litt conveyed tonight.  When asked what advice he was given that served him best, he said, “Imagine someone in your audience will tell their friend tomorrow about your talk.  What is the one thing you want them to say about it?”  What is the Why of your talk?  Even though he no longer writes speeches for the most powerful person in the world, he expressed a desire to continue inspiring, empowering, and promoting personal agency in all whom his work touches. Make each and every audience member their own hero.

It turns out, however, that this approach applies to much more than public speaking.  On my 50 hour, 500 mile, aspen-pursuing weekend in Colorado last month, I described to my dear friend my favorite moments at work.  At the end of a patient’s day-long physical, after I have spent 90 minutes listening to their stories of weight gain and loss, work transitions and complex family dynamics, and reviewing their biometrics and blood test results, I meet with them for an additional 30 minutes to debrief.  This is when I present an integrated action plan compiled by the nutritionist, exercise physiologist, and myself.  It is a bulleted summary of our conversations throughout the day, centered on the patient’s core values and self-determined short and long term health goals, and crafted with their full participation.  I get to reflect back to my patients all that I see them doing well, and shine light on areas for potential improvement.  It’s an opportunity to explore the possible—to Aim High, Aim Higher, as the United States Air Force exhorts.  I often present the plan with phrases like, “Strong work!” “You’ got this,” and “Can’t wait to see what the coming year brings!”  My friend turned to me as we wound through autumn gold in the Rocky Mountains, a bit tearfully, and said, “You make them the hero of their own story.”  Yeah, I do, I thought, and I got a little teary, too.

Words are powerful.  They are our primary tool for relating to each other, for making another person feel seen, heard, understood, accepted, and loved.  You don’t have to be a public speaker or a presidential speechwriter to make a positive difference with your words.  At work, in your family, with your friends, with people on the street and in the elevator—what is the one thing you want someone to remember from their encounter with you?