31 May 2019

Dear Interested Readers,

 

Relationalism and the Joy of Practice

 

I imagine that other retirees do what I do and spend a lot of time thinking about what happened during the years of their careers.  The goal is to be able to say, “It wasn’t perfect, but I did my best, and by the way there are no do overs, so I must let it go.” Saying it is one thing; believing it takes some time and work. It is easy to “Monday Morning Quarterback” yourself and conclude I coulda, woulda, shouda on fifty years of your life. It is hard to let it go, and let it be. I have not yet gotten to the place where I could sing along with Frank Sinatra: 

 

And now, the end is near

And so I face the final curtain

My friend, I’ll say it clear

I’ll state my case, of which I’m certain

 

I’ve lived a life that’s full

I’ve traveled each and every highway

But more, much more than this

I did it my way

 

Regrets, I’ve had a few

But then again, too few to mention

I did what I had to do

And saw it through without exemption

 

I planned each charted course

Each careful step along the byway

And more, much more than this

I did it my way

 

Yes, there were times, I’m sure you knew

When I bit off more than I could chew

But through it all, when there was doubt

I ate it up and spit it out

I faced it all and I stood tall

And did it my way

 

I’ve loved, I’ve laughed and cried

I’ve had my fill my share of losing

And now, as tears subside

I find it all so amusing

 

To think I did all that

And may I say – not in a shy way

Oh no, oh no, not me

I did it my way

 

For what is a man, what has he got

If not himself, then he has naught

To say the things he truly feels

And not the words of one who kneels

The record shows I took the blows

And did it my way

 

Yes, it was my way

 

Pardon the reproduction of all the lyrics, but the song is packed with memorable phrases.  Perhaps we could reduce it to a few bullet points:

 

• And so I face the final curtain [Not something we often anticipate as we travel along]
• Regrets, I’ve had a few [An understatement?]
• I planned each charted course [Highly unlikely]
• Yes, there were times…When I bit off more than I could chew [Almost everyday?]
• I’ve had my fill my share of losing [Letting go the sense of loss]
• To say the things he truly feels [To himself and to others]
• The record shows I took the blows [It’s going to happen, if you push the envelope]
• Yes, it was my way [Owning the outcome]

 

What makes David Brooks’ latest book, The Second Mountain: The Quest For A Moral Life  such a remarkable work is that he picks us up after we have fallen victim to the issues of career and shows us that there is more to a life well lived than career accomplishment. If you would like to hear him in a long, but very interesting interview, just click on the link above.

 

I knew from the moment that I opened the book and began to read his introduction that Brooks had a message for all of us who talk about returning “joy to the practice of medicine.” Brooks begins by describing the difference between happiness and joy. His description of happiness suggests that it is usually a transient reality. My experience confirms that. We can’t hold it long and must continue to search for new peak experiences. Each one fades fast like the pleasure of the last piece of pie.

 

In all forms of happiness we feel good, elated, and uplifted for a while. Brooks spends a lot of time telling us that happiness and joy are not the same thing. It’s important to him that we make a distinction between happiness and joy. He writes:

 

What’s the difference? Happiness involves a victory for the self, an expansion of self. Happiness comes as we move toward our goals, when things go our way. You get a big promotion. You graduate from college. Your team wins the Super Bowl. You have a delicious meal. Happiness often has to do with some success, some new ability, or some heightened sensual pleasure.

 

I guess from that description we should say that we “jump for happiness,” not joy, when we win the lottery. For Brooks joy is a lot more. He elevates the word to a spiritual level that is larger than self and loaded with lasting implications. It is a very special thing that is transcendent and can even occur in difficult circumstances that don’t engender much “happiness” in the moment. He writes:

 

Joy tends to involve some transcendence of self. It’s when the skin barrier between you and some other person or entity fades away and you feel fused together. Joy is present when mother and baby are gazing adoringly into each other’s eyes, when a hiker is overwhelmed by the beauty in the woods and feels at one with nature, when a gaggle of friends are dancing deliriously in unison….

We can help create happiness, but we are seized by joy. We are pleased by happiness, but we are transformed by joy. When we experience joy we often feel we have glimpsed into a deeper and truer layer of reality…

 

It is clear that in Brooks’ experience joy trumps happiness. He even says that a narcissist can be happy, but can’t experience joy because it requires that you get beyond and above yourself and requires meaningful relationships with others, which narcissists can’t do. About a month ago Brooks was the speaker at the Arizona State University graduation.  Following that experience, he wrote once again about the difference between happiness and joy, and emphasized being vulnerable to others in his description of the origin of joy.  The piece describing his experience at Arizona State is entitled, “The Difference Between Happiness and Joy: Staying vulnerable in an age of cruelty.”

 

Joy comes when your heart is in another…Joy is the present that life gives you as you give away your gifts.

We live in a cruel time, when people attack you when they see a hint of vulnerability. So, it’s extra important to stick with emotional honesty even after people take advantage of your vulnerability to inflict pain. Vulnerability is the only means we have to build relationships, and relationships are the only means we have to experience joy.

 

That description explains some of the emotion in “I Did It My Way.” The persona that Sinatra’s song describes has “…had my fill my share of losing” and was vulnerable to cruelty, “The record shows I took the blows,” but the song has always had a hollow, joyless feel to me. Was it because the experience was not shared with others? There is satisfaction looking back knowing that he “did it my way, Yes, it was my way,” but there is more defiance than joy in the recounting of the experience. “We Did It Our Way” might have been a more joyful song.

 

Brooks attributes much of the pain and cruelty that we experience today to the evolution of what he calls “hyper-individualism.” He traces the development of hyper-individualism back to the fifties when an individual’s  agency was constrained by traditional gender roles, the provincial nature of small town life and neighborhood society, and the constraints from the orthodoxy of most religions. The various liberation movements of the sixties put an end to all of that and greatly enhanced personal freedom, but Brooks contends that the pendulum has swung much too far the other way now.  We have so much individualism that we often feel alone, isolated and disconnected from community. Much of what we do, we do alone. Everything we do needs to pass through the eye of the needle that is “self,” and that reality is antithetical to joy. The theologian Marcus Borg says it well in one of my favorite books, Convictions: How I Learned What Matters Most.  He writes:

 

Many Americans embrace the  ideology of individualism. Studies indicate that we are the most individualistic country in the world. As an ideology, individualism is the foundation of conservative politics and economics. It shapes the voting of around 80% of conservative Protestants. Their political passion is primarily about the behavior of individuals, especially issues related to sexuality. Income inequality, economic justice, and a strong commitment to peace are not priorities for most of them.  

The influence of individualism extends beyond political and religious conservatives. It affects how a majority of American Christians understand biblical passages about helping the poor…

 

I hope that statement will not be offensive to you, dear reader. The news today is full of the recent rash of state laws seeking to limit access to abortion. The appointment of Neil Gorsuch and Brett Kavanaugh to the Supreme Court is a real time manifestation of Borg’s point about the power and orientation of the religious right. President Trump would have never been elected and the accomplishments of Roe v. Wade and the ACA would never have faced the potential of reversal without the persistence of the religious right as an expression of a form of individualism that is paradoxically moving toward an authoritarian mindset that tolerates no other points of view.  Nevertheless, I hope you will just take Borg’s analysis as a generalization that may have some truth that is worth pondering and not as an attack on the right of Evangelicals to have a political point of view. Borg’s bias is supported by data from the work of NYU psychologist Jonathan Haidt, the author of The Righteous Mind: Why Good People are Divided by Politics and Religion.

 

Borg shifts from a theological voice to one that sounds like it is coming from an internationally famous epidemiologist like Sir Malcolm Marmot in The Health Gap: The Challenge of an Unequal World.  After a few paragraphs of biblical references to the prophet Amos, Borg says:

 

… the prophetic voices of the Bible are about economic Justice and fairness –changes in the system as a whole– and not primarily about charity to individuals.

The alternative– or necessary complement– to the ideology of individualism is a politics that takes seriously “the common good.”… Countries that take  seriously the well-being of all are safer and healthier: they experience less crime and mental illness, lower infant mortality rate, longer life expectancy, less desperation, and so forth. In all these categories, the United States lags behind most of the developed nations in the world.

 

Brooks is realistic. We live in a real world where Individual ambition, the exercise of agency, and I might add, dealing with the isolation of professional life that is associated with being paid for for how you perform as an individual, are all realities that are associated with “career,” and what Brooks calls the “first mountain.” His metaphor for the the activities on the first mountain is that they form a list of things that belong on your resume. His “second mountain” is about what you do when career has not been enough to bring you joy. The metaphor for these activities is that second mountain endeavors are the things that you would like to have said about you when someone delivers your eulogy. These are the things we do when we pursue a passion that relates to something outside of “self.” They are the activities of our vocation, not necessarily our professions. Our vocation is our “calling.” It is what we feel compelled to do as we seek joy.

 

I think that one of the advantages about all the helping professions is that they have the potential to be both career and vocation. I have known many nurses and doctors whose career was also their vocation. You have known them also. They are the people who “carry” the practice. They coach others. They see the late “walk in” without grumbling. When you are uncertain about a next step in care, you know that you can ask them to listen to your concern, and they will not make you feel inadequate. They are not as interested in scoring points and racking up RVUs as they are in making sure that every patient’s needs are met. It’s not that they are unaffected by all of the time constraints and concerns that we catalog as the origins of burnout, it just seems that they have developed some sort of immunity or draw some protective force from the same realities that undermine others. There is something in the way they approach the work they love that protects them and allows them to continue to do what they love to do even when the environment is a challenge. It has been my observation that these are the same individuals who are easy to engage in conversations about care improvement, the Triple Aim, and resolving the issues of the underserved. They are concerned about individuals, but know that community determines much of the experience of the individual. They are more concerned about the quality metrics of their practice than the details of the latest compensation program.

 

Brooks would say that these people who can remain enthusiastic about the challenges of practice when others are falling prey to the fatigue of the concerns that flow from “hyper-individualism” are practitioners of “relationalism.”  He describes the characteristics of relationalism in detail.

 

Relationalism

 

• The revolution will be moral, or it will not be at all. Modern society needs a moral ecology that rejects the reigning hyper-individualism of the moment. We need to articulate a creed that puts relation, not the individual, at the center and which articulates in clear form the truths we all know: that we are formed by relationship, we are nourished by relationship, and we long for relationship. Life is not a solitary Journey. It is building a home together…

 

• The hyper individualist sees society as a collection of individuals who contract with one another. The relationalist see society as a web of connections that in many ways precedes choice. A hyper individualist sees the individual as a self-sufficient unit; the relationist says, a person is a node in a network, a personality is a movement towards others.

 

• As a child, each person’s emotional and spiritual Foundation is formed by the unconditional love of a caring adult. Each person’s attachment style is formed by the dance of interactions between herself and a loving adult. “We” precedes “me.”

 

• As adults, we measure our lives by the quality of our relationships and the quality of our service to those relationships. Life is a qualitative endeavor, not a quantitative one. It’s not how many, but how thick and how deep. Defining what a quality relationship looks like is the central task of any moral ecology.

 

• The best adult life is lived by making commitments and staying faithful to those commitments: commitments to vocation, to a family, to a philosophy or faith, to a community. Adult life is about making promises to others, being faithful to those promises…

 

• Relationalism is a middle way between hyper individualism and collectivism. The former detaches the person from all deep connection. The latter obliterates the person within the group, and sees groups as faceless hurds. The relationalist  sees each person as a node in a thick and enchanted web of warm commitments. She seeks to build a neighborhood, nation, and world of diverse and creative people who have made commitments in a flowering of different ways, who are nonetheless bound together by sacred chords.

 

• Relationalism is not a system of ideas. It is way of life. Relationalism is a viewpoint that draws from many sources from Edmund Burke, and Martin Luther King, Jr., from Jacques Maritain, Emmanuel Mounier, Martha Nussbaum, and Annie Dillard to Gandhi and Josiah Royce.

 

• The hyper-individualist operates by a straightforward logic. I make myself strong and I get what I want. The relationalist says life operates by an inverse logic. I possess only when I give. I lose myself to find myself. When I surrender to something great, that’s when I am strongest and most powerful.

 

It’s been my experience that the best “medical homes” have been populated by relationalists. I also believe that one approach that servant leaders intuitively promote to diminish the impact of “burnout” is to encourage cultures of relationalism. I think “Lean done right” with leaders focused on coaching, mentoring, and empowerment, is an exercise in relationalism. Professor Rebecca Henderson of Harvard Business School emphasizes that “Relational Contracts” are foundational to the trust that is necessary to build lasting organizations.

 

Population health is a focus on community that can be promoted with “thick relationships” that may engage Community Health Workers. The era of hyper-individualism has taken its toll on medical professionals. The image of the much loved old country doctor in a Norman Rockwell painting may feel quaint, and I am sure he would be confused by our technology and amazed by what we have learned, but we should also realize that he was effective and much admired because he was a master of relationalism.

 

Brooks is a little like the Prophet Jeremiah suggesting that we change our point of view and our practices before we are unfortunate and arrive at the destination toward which we seem to be headed. We have all the tools and resources we need to achieve the Triple Aim and more.  We have the knowledge to work miracles in our time for everyone in our communities. What we need to have is the wisdom to realize that we live in community, and for our own joy in practice we must work together to make it possible for every person to benefit from our collective abundance.

 

I’m Jumping For Joy. May Is Almost Over.Tomorrow Is June, and I’m Excited.

 

Memorial Day, the celebratory beginning of summer, has come and gone. It was a beautiful day that measured up to all its traditional billing. I enjoyed an afternoon at Fenway Park with my wife watching the Sox pound the Indians. Tuesday, was so wet and cold that I built a fire. The Red Sox added to the dreariness by losing a game in the ninth inning that I thought they had won. When I went to bed at midnight at the end of the eighth inning in a rain delayed game, the Sox were leading by three runs. In the morning I discovered that they had lost by two runs.  There was more grief on Wednesday. It wasn’t raining, but there was a chill in the air. The Sox got whacked 14-9. That’s the way May goes. There is one day that gets you excited, and then two days that you must endure.

 

I have high hopes for June. We do have plenty of flowers popping out all over town, as the header for today’s post shows. The white building is our town hall. I have made a few trips back and forth this week dealing with the local bureaucracy as I have tried to register an old boat. The only thing pleasant about the trips was passing through the lilacs that totally shield the entrance. They reminded me of Walt Whitman’s poem that grieves the loss of President Lincoln, “When Lilacs Last In the Dooryard Bloom’d.”

 

The lady loon on our lake is sitting on her nest. If things go by plan, sometime soon she will be swimming around the lake with one or two chicks on her back. It will be summer for sure when that happens. Everything eventually comes full circle. If you look, there is joy to share all around us.

 

Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

Gene