Tag Archives: David Logan

Trust and Safety in an Uncertain World

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Suddenly I felt my heart pounding.  My palms got sweaty.  My jaw felt tense.  I’m anxious, I realized.  It felt like sometimes when I speak up in big meetings.  Wow, I don’t even have to be in front of people for this to happen, how fascinating.

It was the second or third comment I had written on another Facebook page, belonging to a high school classmate.  I think we became ‘friends’ through his wife, a friendly acquaintance of mine in high school, with whom I’ve been connected on Facebook for several years.  I don’t really know her husband at all, and yet here I was, writing long replies on his page about universal masking, why recommendations changed between March and now, and why I trust Dr. Fauci despite his apparent flip-flop on this issue.

I had entered someone else’s house, offering my unsolicited opinions.  Though we have a handful of mutual friends, I had no idea who else would attend this party, and whether I would be welcome.  I wasn’t sure it was safe.

And yet I felt compelled to enter, why?  Perhaps I felt defensive of my professional standard bearer, Dr. Fauci, the father of modern infectious disease and icon of science, medicine, and public health.  He has basically led the research to define and defeat HIV/AIDS since the 1980s.  Through six administrations, he has directed the National Institute of Allergy and Infectious Diseases (NIAID) to successfully manage H1N1, Ebola, and Zika, at home and abroad.  He is one of my heroes.  Likely, I also wanted to absolve myself a little, as I had also recommended against masking in public early on.  I wanted to help some strangers see us, the ‘experts’, as human and fallible, and also earnest and caring, worthy of heeding.

So I obsessed over my comments.  I read and reread before posting.  I edited after posting.  I included the links embedded above, inviting anyone on the thread to hear Dr. Fauci in his own words, in full.  I offered my own mea culpa twice, explaining how academics sometimes fall victim to ivory tower thinking, as we did in this case.  Perhaps this was my attempt at earning back whatever trust people may have lost because we experts contradicted ourselves in such an important and pivotal moment.  I regret this, and I wanted people to know, and then maybe not hold it against me (us).  Would I be crucified?  Or would I crack a door open to hearing what I had to say?  I feel anxious now, just thinking about it again.

My own friends discussed this on my page a few weeks ago, after my post on antibody testing (our recommendations have not changed yet).  Paul, MD PhD and rheumatologist, pointed out, “US experts really blew it initially when it came to masks… All they had to do was consider the possibility that Asian countries might be right and then consider that the risk associated with (masking) was virtually zero.  The first thing experts need to do, when confronted with circumstances that are truly new to them, is admit uncertainty and base recommendations accordingly.”  I’m so lucky to have such honest and direct friends.  I replied that I felt badly for following the ‘expert’ advice like a sheep (which is exactly how others on my acquaintance’s page described followers of universal masking, yikes).  “Lesson learned,” I wrote—but have I really learned it?  David, Paul’s and my classmate who now leads quality and hospitalist programs at his institution, replied, “It’s weird to be here with you (two) bashing experts, since the three of us are by any definition, experts.  But the value of experts is not that they’re always right, but that they have a) a better track record and b) the ability to self-correct.”  Yes, humility is key.

It all makes me wonder, how do we trust someone?  I have conversations every day with patients and non-medical friends and family, educating and advising, and they are appreciative; they trust me.  But we have already established mutually respectful, personal relationships.  What made me think I could go on this unfamiliar man’s social media page, interact with perfect strangers, and have them trust or accept anything I said, when they had already expressed reservations about, if not hostility toward, my ‘tribe’?  Was it my place?

The original post commented on universal masking and referenced Dr. Fauci not in a snarky, pejorative, or aggressive way.  If it had I would have scrolled right by.  Because it was a neutral presentation, I felt it could be safe to enter this house and offer my perspective.  Out of respect for the page owner and his friends, I did my best to present both humbly and objectively, to be informative but not condescending.  I really wanted to put my best online foot forward, to represent my tribe and my profession as well and as trustworthily (it’s a word!), as possible—to connect.  So far I have not been attacked, and a few readers have liked my comments.

In the end, as I have written before, I think it’s about how we show up to one another.  I wrote recently about tribal culture, and how through this crisis, individuals can help our own tribes thrive by modeling a more collaborative rather than competitive mindset, by amplifying our togetherness.  “Who do we want to be on the other side of this crisis?” I asked.  David Logan and colleagues go on in their work to discuss how tribes can effectively interact with other tribes, forming alliances and advancing even greater good together.  They posit that tribes draw closer when their respective members, especially designated leaders (representatives), connect.

We find ourselves now in an existential battle for our lives, literally.  Now is exactly the time to find common ground, step onto it, set up camp, and make decisions from there—to merge tribes.  A friend asked me today, “Who do you want to be now?”

I want to be a connector, I answered.  I will do my best not to contribute to division, polarization, alienation, disconnection, and suffering, through my words or actions.  I will not be perfect.  I will make mistakes.  I will continue to learn and apply.  I will strive to earn and maintain people’s trust.  And I will help make it safe for people to question and challenge, discuss and explore any point of view.  In the face of uncertainty, this is what I can offer.

How Do We Get Better?

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It is Week 5 of sheltering in place for many of us.  How are you feeling?  What emotions occur most often?  To where and on whom are they directed?  How do you see the future, and what does that feel like?

Who do we want to be on the other side if this crisis?

For all our sakes, I hope we can be more patient, kind, empathic, open-minded, thoughtful, intentional, and connected.  The COVID-19 pandemic shows us what ultimate paradox really means—trauma and grief on a scale not seen in generations, as well as an opportunity for unprecedented growth, both as individuals and as a society.

I think about the risks and possibilities as both a clinician and citizen.  The experiences overlap, as do the strategies to mitigate suffering.  I am so grateful that physician burnout and well-being has already been addressed in so many institutions, and at so many levels, before this crisis hit.  Programs like physician peer support and Balint Groups show us that our leadership cares for our well-being, or at least recognizes the need for organizational support of it.  Employee Assistance Programs and the like are much more visible now, and hopefully barriers to access are also down.  Everywhere I see offers for formal organizational support and ‘wellness.’

But what will really make the difference in the end?  How will we really grow into our best selves through this, the greatest global challenge of most of our lives so far?

I think it will be in our small, day to day, apparently mundane interactions.

Too often we underestimate the impact of our milieu on our attitudes, thoughts, words, and actions—how we are impacted by our environment, and how we impact it in return.

A wise friend observed two groups of people responding to COVID-19.  One sees the pandemic in terms of ‘what’s happening to me.’  The other experiences it as ‘what’s happening to all of us.’  This is a falsely dichotomous oversimplification, obviously.  But it may be instructive to notice one day this week, if we were to categorize our own thinking/feeling/speaking/acting with regard to COVID, where would we land more of the time?

I’m reminded of the stages of tribal culture described by David Logan and colleagues in their book, Tribal Leadership, and presented eloquently in his TED talk.  I have discussed this idea in previous posts.

The visual above encapsulates Logan et al’s theory of tribal culture.  Their work aims to advance groups from lower to higher levels of culture and performance.  In this framework, the currency of cultural economy is language.  Each tribe member’s dominant cultural stage mindset emanates in their words, and is represented/encapsulated in each stage’s mantra above.

Those who experience COVID-19 as ‘what’s happening to me’ likely live in the lower three stages most of the time—self-absorbed, competing, uninterested in personal or societal connection and growth.  Those able to see how ‘this is happening to us all’ have made the shift toward an Outward Mindset, seeing their node selves as inextricable members of a larger, interconnected system.  For a system to function well, grow, and sustain itself best through crisis after crisis, it must achieve a collective “We’re great” or “Life is Great” mindset.

Whom do you know on your team, among your friends, or in your family, who lives these words (most of the time)?  How do you feel when you’re around them?  What do you hear them saying right now? What energy do they exude?  When I meet people like this in my life, I feel calm, soothed.  They remind me to be humble, and to remember what I can do to help, both myself and others.  I feel connected in their presence; I recall my strengths and potential for contribution, and I’m motivated to act accordingly.  They give me hope.

So what do I hear them saying, what language do they speak that elevates our communal culture?

First, they avoid ad hominem.  They refrain not just from political rhetoric and attacks; they don’t make generalizations about groups based on race, gender, geography, social class, etc.  They also withhold judgment—they entertain various stories about people’s motivation, circumstances, and values, rather than jumping to oversimplified conclusions based on their own biases.

Second, they empathize.  They strive to relate to each person they’re with, as well ‘the others’.  And if they can’t do that, they validate the others’ feelings.  “That’s so hard,” can be the most soothing words a person can hear when they’re struggling and suffering. And “Well, we don’t know what they’re living,” reminds me to be humble.

Third, they offer hope.  But it’s not false hope or superficial, Pollyannish positivity.  They honestly believe in and see the light at the end of the tunnel, and they point to it for our benefit.  They do this by asking, “What do you need?”  “How can I help?” and saying simply, “I’m here.”

When I come across people like this, I want to be around them more.  I want to emulate them.  I point out their words and actions to others, and show the positive movement they inspire in me and others.  Stage 4 and 5 tribal leaders lead by example.  And make no mistake, they are everywhere.  They often don’t have a title or any designated authority.  But the team/organization/family is always better for their presence.

If you have people like this on your team, consider:  how can you be more like them?  What do they inspire in you?  If you are this person, how can you bring people along in this mindset?  This is how we get better through our current crisis:  We find the leaders who speak the language of We, Together, Growth, and Hope.  We find and follow those who set the example, and we strive to set it ourselves.  We take advantage of the programs and support systems around us.  We get help, get better, and then turn around and help others.

Yes, there is much trauma and grief.  There is also boundless love and connection.  We find the latter easily when we look, and it sustains us.  We can absorb that energy, join that movement, and make a difference in every encounter with our fellow humans.  We can absolutely be better.

 

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.