Creating Healing Cultures

“I thought that I would just finish medical school and go hang out my shingle and it would all work out, somehow.”

Ava

 

A disappointing testimony to my age is that references to the old TV drama, Marcus Welby, MD, have become irrelevant to our newest physician partners. This great previous iteration of doctor culture gives understanding to some of the expectations that were imagined by many physicians before they entered medical training.  The dissonance between the realities of being a contracted partner in a medical group and the preconceived notion of autonomy in private practice can breed anxiety for physicians.  In one thought the doctor is the nexus of the healing environment for a community of people and in the other they are part of a collaborative team that seeks healing as a group process.

In one caregiver session I recount the comment, “Don’t ask for me to give up my autonomy unless ‘you’ are excellent.”  The inference was twofold – first in that the doctor was feeling a sense of loss and; secondly, the entity to which he was surrendering his own personal hope for excellent patient care was in some way NOT fully excellent.  An unspoken plea is that the sponsoring community should step up its game. It is a bit like Tom Hanks’ dying comments to Pvt. Ryan, “Earn this.”  Another associated insight is that there seems to be an unrelenting belief that they, the physician, are the only true point for discerning excellence and that excellence is exclusively defined by the quality of the patient care.  This becomes a fulcrum for ethical concern going forward as we discern pathways for care into the future where resources become even more limited.

During conversations about “just culture” and how healthcare is trying to deliver more care to more people for less money, the physician who is concerned about loss of autonomy might interpret this strategy as “less money, less time, less quality care.”  It is easy to see complex strategies that seem to rob time, money and the perceived negative effect on quality outcomes as being implemented on the backs of the physicians.  Managing a sense of freedom is less about money and time and much more about “voice” and possibly more appreciative sway in decision making.

The physician partners relate a perception that they are losing control over some aspects of the care environment.  This comes from comments describing loss of influence over finance, decision making, staffing, general facilities support, and so on.  Inside most of the discussions referencing loss of autonomy a common theme of communication, or rather a breakdown in communication is prevalent.

One final observation on this topic is that concern of loss of autonomy remains largely undefined in its most universal sense in so much as there does not seem to be a working definition that everyone agrees upon for what loss of autonomy really means.  For some it is loss of relationships, others see loss of control over their practice, decision making, contracts, income, or almost any number of individual aspirations on which expectations might have been shattered.

Several reasons can be misinterpreted into perceptions of why autonomy is strategically being limited in future models of care deliver: loss of ownership, control, capacity to influence, or even freedom.  There is a much deeper implication that the word “autonomy” offers as a catalyst for empowering behavior that seems important to understanding a potential breakdown in culture.  For instance, if we were to desire loyaltyas a key nature of the physician culture we seek to create, then it seems obvious that we might nurture an environment in which loyalty can be given. Loyalty to team, to leadership, to culture, to enterprise – whichever is the target of our hope would also become the object from which we convey want for loyalty.  A key component of loyalty is that it can only come from the freedom to either give it, or withhold it.  It is completely possible to feel loss of autonomy and be a compliant, passive participant.  Any environment in which compliance is achieved yet does not include the protected, autonomous nature of the partner can only be interpreted as coercive in its nature.

It is impossible to give away something you do not possess.

Negotiating …

Imagine you are feeding a baby cherry pie for the first time.

 

 

Sarah:Lauren

 

Here is a story in three buckets.  They may not seem to connect at first but if you will bear with me to the end you may reason differently.

BUCKET ONE: Potato; Potato!

40 light years from Earth a planet called 55 Cancri E orbits blisteringly close to its host star and due to the fact that it is largely made of carbon, with a density 8.5 times that of Earth, it seems to be about 1/3 made of diamonds.   Yes, this is De Beers greatest nightmare.  Enough diamonds to convert the value of Earth diamonds to roughly that of Earth dirt.

The scarcity of a good sharpens our clarity in assigning value to it.  Just like abundance, or need might tip the value for the which we seek to trade. We have to reason a lot of personal context/need/want/influence/emotion and stuff to make a good trade.

So, who’s to say what a goat is worth except the person who needs a goat?  The purchase of Manhattan (referring to the beads), The Louisiana Purchase, and Alaska were all “good deals” for both parties.  Negotiating is based on understanding the needs of those who have what we want.

BUCKET TWO:  We trade stuff emotionally

In marriage counseling a rule of thumb is that the “power” in any relationship exists with the person who “needs” the relationship the least.  This means that when we do the mental math on what our partner brings to the party and we don’t see them ponying up the same amount of effort that we believe we are putting into the relationship then we experience a perception of imbalance where one person needs the relationship less and therefore can make demands without experiencing as great a consequence.  This is not a healthy relationship (just making sure you remember).

Equity is necessary for people to coexist together, but what is equity in a relationship?  It isn’t money, right?  It is whatever value that you place on what the other person provides that you cannot provide yourself and what value you are willing to give of yourself to that person in order to create a mutually beneficial relationship.  Perceptions in healthy relationships that sense balance are usually based on things like personal dignity, emotional affirmation, and safety.  The more tactile the transaction of a marriage’s currency of exchange; the less likely the perception of balance can be achieved (just to make sure you remember – sex is a really great tactile item of mutual exchange, but should not be leveraged as emotional currency, rather a product of mutual respect that results from a healthy balance that already exists in the relationship).  One definitely comes before the other.

Once again, we find a value system where both participants are very much driven by personal reasoning about what is important to them and calculating a worth to an experience from which we reason deeply personal things like esteem, purpose, identity and our worldview.

BUCKET THREE:  Why “why”?

The principle of  integrity states that if we only look at a person’s motives for actions without judging her/his intentions then we are only partly seeing that person’s context and potentially failing to be a partner in healing.  Motives are things like jealousy, hunger, rage or greed.  Each can pull us toward any goal – good or bad.  If judged alone without consideration of reason then we cannot see the humanity of how a person may have been weighing out options and intentions.  Humans can reason NOT to steal a loaf of bread if they are hungry.  NOT to kill out of rage; and, NOT to destroy from a sense of self-gain.  Reason becomes a staging area for our thoughts where we pause in collection of many different tangents of how our actions will impact the world and we reckon which way to act.

When you negotiate in relationships or business, do not fail to consider intentions and reasons in addition to the much more easily seen motives.

CONCLUSION: Your intentions are “everything”!

In the Bible story about the Woman with an Issue of Blood (Luke 8:40-56) people were pressing on Jesus from all sides in hopes of receiving something.  A miracle, a cure, entertainment, we cannot know precisely except to realize that they were “thronging him” to get it.  When, in duress, the woman waded through the pack and “touched the hem of his garment” she was healed.  Why her?  A whole bunch of other people were touching him, too.  But in an almost humorous expression of split personality Jesus asks, “who touched me? I felt power go out from me.” As if his power acted without his permission.

What was the reason? What balancing act from reason allows one person to receive an inconceivable gift in a crowd of people wanting to get the gift?  The answer remains the same as all of the above scenarios of transaction.

Consider how reason works when disproportionate wealth and lopsided capacity relates to impoverishment in a way that results in mutual value. I.e. a rich person and a poor person.

Imagine you are feeding a baby cherry pie for the first time. The joy of sugar is awesome!!! And yet in the shear ecstasy of experiencing the most wonderful thing in its new little world she reaches up a dirty handful of pie for you to taste it too. The person feeding the child in no way needs the one messy bite of pie but reasons it as a perfect gift.  Almost no other option can be exercised except to receive the offering and enjoy the messiness of the child’s sacrifice.

In the same way Abram believed God (Gen 1:6).  God reckoned his faith as righteousness.  In no way can Abram stand in perfect righteousness unless God reasoned it to be so.  Reason is the fulcrum for discerning value.  Some might say that this particular negotiation was a “bad deal” for God.  The balancing of transactions in order to reach equitable dignity and integrity is called grace.  So, what might be in it for us that we could value “giving grace” as a part of our “receipt” of goods exchanged in this transaction?

It is entirely likely that the best negotiations are always balanced.  Salt for service.  Money for goats. Grace for faith. And, it is equally likely that imbalanced trades are “one-offs” that leave one feeling cheated and unwilling to continue in that relationship.

Sensing other’s needs and how they might value what they can give allows us to better receive what is offered.  Great gifts sometimes look like dirty little hands covered in goo.

So please enjoy some balance today and go negotiate some grace to all the “debtors” in your life.

 

Peace

 

Yes, everything in this article is a repost from an unread previous blog.  You’re not crazy. I reposted to see if repackaging works.  New photo, new headline, etc.  You’ll let me know.  In the meantime. Don’t make the mistake of thinking that this whole article wasn’t about relationships and love.  

Change?

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“Change is like the wind.”

This time of year is such a wonderful reminder of how beautiful change can be.  Although, for some of us change is not always beautiful and can even be a bit frightening.  In business, in healthcare and in relationships we often see change as a disruptor of the norm. It seems unsafe. Therapists propose that traumatic changes like loss of a spouse, job changes, moving homes can be opportunities to insert positive new behaviors like stopping smoking or dieting.  We are most likely to make and sustain new habits in the context of turmoil and change. The discomfort of change can hold opportunity for good if we are intentional.

So why do we spend so much energy in creating predictable, safe environments in which to live and hope that change does not find us?  The only certain thing about change is that it’s always going to happen.

Try to consider these three ideas when facing change:

Expect it.

When my wife and I traveled to drop off our son to college we had a conversation about the changes in relationship that always accompany home dynamics (she’s so lucky to have married a counselor – although she might not admit it some days).  It was almost comical when we found ourselves fighting over some trivial “nothing” on our way back home after leaving our child in what was his first solo grown up home, St Olaf University dormitory.  We began laughing at each other in unison recounting that we knew this would happen and even expected it.  After we each apologized we regrouped in the knowledge that we would survive together even separated from our child by distance. A courageous leader will try hard to prepare her/his people for the inevitable storm.

Reframe it.

A great quote from an old book, Dying for Change states, “At the last great meeting of the species the dinosaurs voted unanimously NOT to change.”  We only have three choices when it comes to change: retreat and guard the doors against letting it happen, remain catatonic and let things overwhelm us, or face it – march into it and in wonder find the promised good.

Change is not a variable like we sometimes may treat it.  It is a constant promise that can act as a form of hope in our lives. Placing the dynamic vortex of mystery and the unknown in a frame of mind that keeps change ever present and thrilling is the very excitement that prompted us to first ski a black diamond slope, sky dive or get married and have children (like we “planned”).

Grab hold of it.

Being raised in the flat, no trees environment of West Texas offered a uniquely bizarre perspective from its strong, sustained blasts of wind.  Learning to lean into it.  As a child, I would flare out my wind breaker like wings and let the wind keep me from falling flat on my face while dangerously leaning forward in a way where I would most certainly fall flat on my face if it were not for the wind.  Leaning into the wind is strangely empowering. It is like standing next to something wild and not being consumed, or wading in a muddy river.  Change is like the wind.  “We don’t know from where it comes, or where it goes.”  But, we CAN have confidence that it will only reframe our future, not destroy it.

The discipline of hope is that it provides vision beyond change into what we might create, compose or dare to become. First and always have hope. Never let it go.

Sure, we will probably get soaked . . . but just look at that awesome wave!!

 

 

 

 

 

Perfect positive regard . . .

“If you can’t sit across from someone and say to yourself in all honesty, ‘I have perfect positive regard for you.’ – you’re never going to do that person any good.  Just walk away.”

 

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He left home at a young age to work on a fishing boat in California with our uncle.  Later, he went to Vietnam with what was then a little known government group called the NSA.  He exhausted his GI bill on every ounce of education he could get and remains a life long learner.  As life passed he became a seasoned sea captain able to sail ships of all sizes and shapes.  Then he met a redheaded wonder who he could not walk away from and they married late in life, turning Mike into a land bound counselor of some of the toughest young kids in the Bronx.

As life’s poetry would have it he is precisely where he is needed.  The kids he counsels are tough people who are sometimes tough to love.  The secret Mike shares is that they don’t need to be placated with nice gestures and professionalism.  They each need to be seen as a person who counts for something.

It probably is not fully possible to absolutely always have perfect positive regard for every single person whom you encounter, but I propose to you that the more you try the more you find high regard.

Being in caregiving means that we move into people’s lives at a speedy pace while just the opposite is true for our patients – everything is in slow motion.

Tell someone that you hold them in high regard and see what happens.  Find out why it is true for you to say, “I hold you in perfect positive regard.”

 

And with passion he said, “PASSION!”

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Dear Friends,

Last night I had the amazing privilege of having dinner with Lou Holtz (yes, the coach from Notre Dame).

Having no ability to control myself I commenced to ply him with questions about leadership and growing talent.  I asked, “Given that in your career you’ve walked into at least 5 major teams – full of talent but not winning games – what would you say is the MOST important thing to look for first in creating a team of winners?”

Almost before I could finish the sentence, and well before he’d finished chewing what was in his mouth he loudly spit out, “PASSION!!”  “I look for passionate people who want to take the whole team into a new place.  Passion!”

He went on to describe how having passion was the absolute, fundamental, essential trait that he looked for from his first group and that as freshmen became juniors and seniors he said, “by then, they better ALL be leaders”.

His strategy was to assign a junior and a senior leader to each one of his new freshmen.  Their job was to instill courage and passion.

Reminiscing, he cited a common thematic obstacle that arose in first year players – “quitting”.

“Quitting is a quick, long term solution to what is almost always a short term problem”; “The leader’s job is to tell them to stick it out”

Throughout the evening he kept saying simple axioms like:

“I’ve never told anyone what to do; just the way that I did it. So, I’d say, ‘when I did it this way it didn’t work. When I did it that way it worked. You do what you want to.’”

Humble guy.

Great leader.

Coach Holtz never claimed great wisdom, extraordinary intellect, or anything special that makes him different than anyone else.  Just that he’d survived to say “what worked”.

Had to pass this great experience on to you because of who you are and what I’m asking you to do with the mentoring program.  What we are doing is simple – not brilliant.  Working alongside others to embolden the good and subdue doubt and fear is an old strategy – very ancient  . . . and wise.

Stay simple and survive, my friends.

 

It’s been a while . . .

A couple of weeks before my mother passed away she held her youngest great-granddaughter for the first time.

IMG_1734. . . since we’ve talked.

Few things give greater witness to my shortcomings more than the confusing speed of time passing.  During the past months I have been pursuing education and other distractions and failed to post regularly.

Intentions mostly give way to time passed by as my goals seem to be in a perpetual state of amendment.  Nonetheless, here is a new goal.  To write to you more often.

In coping with my lapses of “doing” I project onto each of you that you are like me.  So, since we are the same then it must be true that you have good intentions too; and, you would like to talk more, take more time in pause, and still have time left for family after work.

A physician friend recently reminded me of the difference between seeking excellence and perfectionism.  She said that excellence is the insight that you will never know or be completely perfect but in the humble state of hope you push toward a goal that will never be achieved and the walk becomes a prayer.  Perfectionism is the disease that we pursue a goal from a sense of failure, or competition not realizing that it cannot be achieved by any of us and this walk is haunted with angst.

A gift to you, time knowing that we all wish we could do more and be more and simply will not get it all done.

“Walk humbly before God”.

Peace