"Wait...What??!!" moments - Part 7

Professional Identity. It’s best to speak in positive terms but I’ll start this definition of professional identity from the breach. When you finish this, please drop me an email to disagree, challenge, amplify. Your comments will generate a future post.

Please take a look at this 1-minute youtube video of Marcus Welby, MD. https://www.youtube.com/watch?v=SJBg6EYrXGs then let’s talk.

This popular (1960s) television doctor expected patients to come to him on his terms. He expected them to follow orders or risk his contempt. He freely shared his judgment, sure that it was good medicine. When his patient asked a question, impatient, he got louder.

If you asked him to describe a physician exemplar, his answer might be that the state of medical knowledge - alone - was the measure of the doctor. Today, we value patient autonomy, shared decision making, the therapeutic relationship, knowing the issues and motivations of our patient, and knowing that it is what is in them that gives them the power to make favorable (but challenging) changes.

So, what is our ideal professional identity? The answer is a series of questions: who am I and who do I aim to be? What qualities in myself do I prize and what qualities would I like to develop or refine in order to be satisfied with my journey as a physician? Who we want to be influences how we interact. Reflection and practice are how we get there.

Step one is to accurately identify one’s own inner frame of reference, one’s moral center. I say “accurately” because humans can be hyper-self-critical or insufficiently self-critical. I say “moral center” because ours is a moral profession, grounded in the outward concern of the well-being of others. Intelligence, optimism/pessimism, insight, bias. Our depth of understanding of the characteristics that have helped or hindered us, who we are, is the start.

Our core personal identity is seasoned by society’s expectations of us as physicians (e.g., competence, respect for patient autonomy, honesty,) society’s hopes (e.g., empathy, patience, kindness,) and what we have absorbed - often unconsciously - as we have risen step-by-responsible step within medical culture.

As students, knocking on the door, to trainees, seeking competence, through to full membership in the profession, we have had sentinel experiences. Our first dissection in the anatomy laboratory, our first patient death, the exceedingly brilliant and empathic attending who we would want to be like, and the attending who publicly mistreated students or trainees, all of these shaped us, helped delineate the “Who am I” question. Reflecting on them in light of who we aim to be is decisive of how we act. Our professionalism arises from our identity.

“Have I accorded this individual’s gift of his body appropriate reverence? “How did I bear witness with this dying patient and her family? “What made that attending so knowledgeable and so kind? What drove this attending to speak that way? Was the act tailored to achieve the goal? Do I want to emulate that conduct?”

Questions of professional (and, really, personal) identity occur to us in the moment but, with greater clarity, we ask these questions of ourselves over the years. We use these questions to actively shape our personae, our personal and professional identity and the environment in which we act. In that way, we assure that we succeed by our own high standards. What follows from knowing ourselves and, increasingly acting more and more in line with revealed values is a deeper capacity to hear our patients and to be better physicians, colleagues, and friends.

"Wait...What??!!" moments - Part 6

DELIBERATE PRACTICE

It seems like magic when we observe a good communicator. How did they know to do what they did and choose just the right words? We wish we could be like that. The wish is brief, then we get back to our to-do list. We often judge our own relative amateur status, then move on, never giving ourselves the credit that we could get ever closer to our desired characteristic. We don’t sustain the thought. We don’t nurture the thought. The deliberate practice of reflection is giving our actions and our goals a “good think”.

Ericsson said that to become expert at any skill, one needed to set goals, critically focus on specific weaknesses, and devote undivided attention to improvement. That’s why we spent time tying knots. When we committed to lifelong learning and when we bought into the concept of relationship-centered care, we accepted - at least intuitively - that every interaction has the power to support or erode the elements of our relationships with teams or with patients. When we commit to deliberate practice of communication, we commit to having honest, constructive self-evaluation and open, direct, constructive interactions. With time, those interactions become System I, intuitive, part of who we are.

When we take time to judge the edges of our communication competence, the sources of bias and error in our thinking, the situations that went well and those we’d like to have gone better, we can set ourselves up for success because we learn to see those critical moments before they arise (fatigue, multiple admissions, work with that one colleague…) or recognize them when they arise , skillfully navigating to calm waters. We Think.

Or, in today’s academic coinage, “reflect”. With discipline, we reflect in, on, and for action. Reflection on action is thinking about something that has happened and taking its lessons. Did it go well? If so, why? The assessment prepares one for the next time. Reflection for action is preparing for the next time using the lessons one has learned, for example, the next time one must give tell a patient unwelcome test results, respond to a surprising or intrusive act of another, or the next time one must evaluate an employee’s performance. The practice of reflection on, and for action, will aid us in reflecting in action. Reflection in action is when it counts; that’s what we are setting ourselves up for. What do we observe about the situation, the others involved, and ourselves in the moment. How have people responded in the moment? Has someone’s history, presentation, or actions caused an affective reaction in us? What adjustments should be made as we continue the interaction in order to get the best result from it? Commitment to reflection in, on, and for action in interpersonal communication is the critical part of our education that, in many cases, took a back seat to basic sciences. No offense intended (indeed, thanks!) to our basic science professors!

"Wait...What??!!" moments - Part 5

Who are we? Our professional ideals, termed Professional Identity, is a complex construct. Ideally, to name a few qualities, in the situation presented in our January 7 post, informing our patient and her family of her Stage IV malignancy, we are kind and supportive, our language is skilled, clear. When our friendly colleague enters and interrupts, ideally, we communicate with her in a way that shows we are committed and caring in all of our roles. We want to gain control to support our patient simultaneously being kind, skilled, and clear with our colleague.

Skilled communication is not genetic. We learn it over time, often without instruction or coaching except for those lessons our parents taught us years ago.

In medicine, we have a compelling origin: at our core, in deciding to go into medicine, we wanted our lives to stand for something good; we wanted to do positive, productive, constructive work for others. When we sift through the complexities of today’s healthcare environment, this core is our evergreen. We do not want to shed it no matter what urgency or emergency confronts us.

Any new situation gives rise to dual responses to varying degrees: emotional and cognitive. Our goal in the myriad contacts - relationships - we have each day in healthcare is for our cognitive response to determine our reactions, not our emotional response. The clearest example is the code. We expect ourselves to be in control and thinking, not emoting, because we know the lives depend on it. Likewise, how we relate to others sets the stage for their cognitive/emotional response in future happy, irritating, or emergent situations.

Gaining skill and control and staying kind and supportive requires deliberate practice of reflection. I won’t go further this week because this is a moment when some of us say, “Oh, this is touchy-feely.” It is not. It is our emotional responses - not well thought out - not in tune with our professional ideals - that are touchy-feely and get us in trouble. Our cognitive responses, aligned with our professional ideals, are what allow us the continual improvement in skill that we seek in all areas of practice.

I will stop right there this week. Please: Can you accept my earlier premise that our work is done in the context of myriad brief or deep, single or longitudinal relationships? Does it ring true to you that we often wish we knew the perfect response in the moment? Does Cognitive Load Theory make sense to you? If you accept these premises, let’s move forward together next week to consider deliberate practice of reflection. Following that, we will flesh out the concept of professional identity, then problem-solve our response to this or any Wait…What??!! or Slowing down moments.

"Wait...What??!!" moments - Part 4

Let's flesh out cognitive load theory one further step. As physicians, we customarily use System I thinking as we go through our days. System I thinking is thinking on automatic, using heuristics, relying on patterns we have experienced over and over again. It is effective and efficient in most situations. When presented with information that doesn’t fit - or situations that disturb us - like someone insensitively interrupting a life-altering conversation - we have to switch to System II thinking which is more effortful, more conscious, and slower. Poised to proceed as planned, we are suddenly jarred to a different place.

Surgical literature has a term for these moments: slowing down when you should. When a surgeon begins a routine procedure and encounters aberrant anatomy, she slows down to inspect and proceed carefully, respectful of the new perils the situation may present. An attending surgeon assesses a trainee as to whether he appreciates the new situation, slows down, studies, and proceeds with care. Like almost all operations, many human interactions in the course of our days, require us to smoothly switch between System I and System II thinking. Some slow down moments are foreseeable, some not.

Slowing down when we should, switching between System I and System II, is a sign of expertise, of practice. Using what we have framed so far, we will next focus on a deliberate practice that helps us build the types of responses we want to Wait…What??!! moments. It may sound like you don’t have time for this. Bear with me. When we relate this to your professional ideals, it will become System I, automatic, a part of who you are, even when sleep-deprived or interrupted.

"Wait...What??!! moments - Part 3

While your patient and her family are gobsmacked, you are constantly assessing whether they seem to understand or not, whether you can add more information, whether they need time, whether it is time to add support or silence, whether they are in a position to make choices. Your thoughts are more deliberate and deliberative than your patient’s and her family’s; you’ve been through this before.

When that new healthcare worker comes through the door, it’s not surprising that some bits and pieces of information the family have heard can be lost or misplaced because of the surprise and the jarring difference in mood, the new demand for attention that the well-intentioned person brought into the room. Their working memory has been overwhelmed; their cognitive load has been exceeded.

Cognitive Load Theory - yes, there’s a lot of research behind this - holds that working memory is limited while long-term memory is practically unlimited. We must work in order to digest information, put it into long-term memory, and free up working memory.

There are three types of load. Any time we encounter new information, there is mental energy we expend in order to process the information and memorize or develop a framework for thinking about it, termed “germane load.” The inherent difficulty of the information is termed “intrinsic load.” Finally, the way in which the information is presented - is it logical or haphazard? Is it in plain language? Is it coming in the midst of jarring interruptions? - is the “extraneous load.” For our patient and her family, the intrinsic load itself may exceed working memory because we may be talking about cell types, medication efficacy, treatment side effects, - things we integrated and developed heuristics for years ago. How can we be alert to whether others’ (or our own) cognitive loads are at capacity? How not to make them overflow and lose valuable content?

Once stored, we, our patients, and others involved in health care have characteristic ways of using information. Now that we have this framework, next session, we will take a bird’s eye view of ways we think about how we use our working or our long-term memory. With this background, in later posts, we will use what we have learned to decide our responses to Wait…What??!! moments.

"Wait...What??!!" moments - Part 2

What is happening to us and to the family in our scenario? Everyone in the room, meaning the physician and the family, is in a thinking, learning state. What is happening in our constant thinking/learning/teaching health care environment?

When we are thinking/learning/teaching, we are using working memory to understand the bits and bytes that we see/hear/say. Take the family: you are giving them a fair amount of information and the information is both complex and freighted with meaning for them. They likely are thinking “Why did this happen?” “What can be done?” “How long do I have?” “How will I explain this to others? Or not?” There are so many simultaneous thoughts and questions; I call this cognitive noise until the thoughts can be teased apart.

Working memory is limited. This family can integrate a limited number of new facts - actually single digit amounts - until they can place that information securely in long-term memory, freeing up more working memory so that they can react, figure out what questions to ask, deal with the embarrassment they may feel by being seen in a vulnerable state, deal with vulnerability while carrying a self-self-expectation of competence. Next post, we will look at the thoughts going through your mind, then begin the framework.

A mini-course: Effectively Handle “Wait…What??!!” moments

You are carefully sharing with your patient and her family the tissue diagnosis from her open biopsy the previous day. The news is not good. Your patient lies pale and weak in the bed having difficulty accepting the information while her husband appears stunned and tears are spilling down her daughter’s cheek. Suddenly, another healthcare worker barrels through the closed door without a knock, and cheerily, playfully introduces themself and communicates their agenda. You are momentarily stunned; let’s call it a “Wait…What??!!”-moment.

“Wait…what??!!”- moments happen frequently in busy clinical practice. This month, let’s look at what happens to us in Wait…What?!-moments. We will build a framework for thinking about these moments so that we can respond to them in the moment in ways that help and that feel positive to us. We want to respond consistent with our ideal professional identity.

In the following weeks, we will dissect what is happening with the individuals in this room. We will consider these individual reactions in a framework that will help us be intentional and constructive when we respond.

Please send an email if an aspect of what you read in coming weeks intrigues you or if I need to expand on what you see. My goal is to make this as useful as possible to you. Thank you for your attention.

Relationship-centered care

We do our work via our relationships. This includes relationships with patients, colleagues, nurses, physician assistants, other professionals, and institutional leadership. Those relationships may be brief and relatively limited in scope or longitudinal and quite deeply involving. Trust, respect, integrity, empathy, and affective engagement are among the reciprocal duties of participants in healthcare relationships; when our relationship are not working, we must reestablish these elements. Our relationships are key to the well-being not only of patients but of everyone in the healthcare web.

Begin to understand healthcare relationships with Relationship-centered Care; A Constructive Reframing, by Mary Catherine Beach and authors from the Relationship-centered Care Research Network in the Journal of General Internal Medicine, 2006;21:S3-8 and An Endangered Ethic - the Capacity for Caring by Marin A. Adson in Mayo Clinic Proceedings 1995;70:495-500.

[W]hat do I want in a doctor? I would say that I want one who is a close reader of illness and a good critic of medicine….not only a talented physician, but a bit of a metaphysician, too. Someone who can treat body and soul. I can imagine [my ideal doctor] entering my conditioin, looking around at it from the inside like a kind landlord with a tenant, trying to see how he could make the premises more livable. He would look around, holding me by the hand, and he would figure out what it feels like to be me. Then he wold try to find certain advantages in the situation. He can turn disadvantages into advantages…We would wrestle with my fate together.

Anatole Broyard, Intoxicated by My Illness; And Other Writings on Life and Death. Fawcett Columbine 1992.

PATIENCE

"PATIENCE SEEMS TO BE MY GREATEST NEED AS I PRACTICE MEDICINE AND IT IS THE SKILL I HAD THE LEAST TRAINING IN AT HOME OR AT SCHOOL. SURELY DOCTORS GET IN TROUBLE MORE FROM LACK OF PATIENCE THAN FROM INABILITY TO REPRODUCE THE COMPLEMENT CASCADE FROM MEMORY. WHY AREN'T WE TESTED ON PATIENCE/IMPATIENCE? I WILL PUT PATIENCE IN THE CATEGORY OF GREAT THEMES THAT ARE CRITICAL FOR THE PRACTICE OF MEDICINE THAT ARE SELDOM MENTIONED, LIKE THE FACT THAT WE ARE GOING TO WORK WITH SICK PEOPLE, WHO ARE SUFFERING FROM LOSS AND FEAR AND INCREASING DISABILITY. NOBODY EVER TOLD ME ABOUT THAT. MY TEACHERS ASSUMED THE DAILY PRACTICE OF MEDICINE WAS LIKE CHILDBIRTH: THE UNINITIATED HAVE NO CONTEXT FOR APPREHENDING THE TRUTH OF THE EXPERIENCE, AND THOSE WHO DO FIND IT TOO PROFOUND TO DESCRIBE."

FREDERIC PLATT. CONVERSATION REPAIR; CASE STUDIES IN DOCTOR-PATIENT COMMUNICATION. 1995. LITTLE, BROWN & CO..