You might think that I am at a disadvantage posting this article on election day. The analysts and most of the polls suggest that Clinton will probably be the winner, but all of them are hedging their calls. I place the most confidence in Nate Silver at 538. I am writing with the belief that what will make the biggest difference to patients over the next four years will not be determined by the election or in Washington, but will be driven by the mindset and objectives at the point of care.
I am a political progressive and do believe that government can make a difference in our search for the Triple Aim. The president and party in power do make a difference, as does the control of Congress, but the biggest determinants of the future of healthcare lie with its professionals. This belief enables me to write about the benefit of a positive mindset at a moment of uncertainty.
For years now I have facetiously declared that medical school is simultaneously an elaborate vocabulary lesson and an immersion in a cult. I was not prepared for practice when I graduated from medical school. I am sure that my medical school was hoping that I would really learn how to practice during my experience as a house officer and fellow. In retrospect I can say that I was still learning how to practice many years into the experience of practice. Looking back from the perspective of retirement, I see that I was learning things on the last day I worked that I wished I had learned in medical school.
Over the last decade or so there has been a lot written about the importance of “being present” in all our interpersonal and professional relationships. Closely connected to being present is “emotional intelligence”, or EQ. For years I labored under the influence of superficial descriptions of EQ. Those descriptions suggest that we focus on being aware of our own emotions and empathetic to the feeling of others. This point of view is summarized by Michael Akers and Grover Porter, two writers who have given us a brief article describing EQ that is available on the Internet. There is truth in their five part description:
The Five Categories of Emotional Intelligence (EQ)
- Self-awareness…The major elements of self-awareness are:
- Emotional awareness. Your ability to recognize your own emotions and their effects.
- Self-confidence. Sureness about your self-worth and capabilities.
- Self-regulation…A few of these techniques include recasting a situation in a more positive light, taking a long walk and meditation or prayer. Self-regulation involves
- Self-control. Managing disruptive impulses.
- Trustworthiness. Maintaining standards of honesty and integrity.
- Conscientiousness. Taking responsibility for your own performance.
- Adaptability. Handling change with flexibility.
- Innovation. Being open to new ideas.
- Motivation. To motivate yourself for any achievement requires clear goals and a positive attitude…Motivation is made up of:
- Achievement drive. Your constant striving to improve or to meet a standard of excellence.
- Commitment. Aligning with the goals of the group or organization.
- Initiative. Readying yourself to act on opportunities.
- Optimism. Pursuing goals persistently despite obstacles and setbacks.
- Empathy…An empathetic person excels at:
- Service orientation. Anticipating, recognizing and meeting clients’ needs.
- Developing others. Sensing what others need to progress and bolstering their abilities.
- Leveraging diversity. Cultivating opportunities through diverse people.
- Political awareness. Reading a group’s emotional currents and power relationships.
- Understanding others. Discerning the feelings behind the needs and wants of others.
- Social skills…Among the most useful skills are:
- Influence. Wielding effective persuasion tactics.
- Communication. Sending clear messages.
- Leadership. Inspiring and guiding groups and people.
- Change catalyst. Initiating or managing change.
- Conflict management. Understanding, negotiating and resolving disagreements.
- Building bonds. Nurturing instrumental relationships.
- Collaboration and cooperation. Working with others toward shared goals.
- Team capabilities. Creating group synergy in pursuing collective goals.
Despite resonating with this outline of EQ, I now think that I was missing a major point which is also very important to “being present” and mindful. If one is to possess a highly developed emotional intelligence and can be truly “present”, one must also be able to be accurately aware of their impact on others, and also care about how they are experienced by others. Without an ability to be aware and care about how you are perceived by others decrements your EQ.
It is easy to see the impact of defects awareness and EQ in others but very difficult to recognize one’s own deficiency, especially when there is an element of certainty in the “rightness” of one’s cause or opinion. I think that it is missing in many healthcare professionals, clergy, politicians and many people who earnestly want to be leaders and contributors to improvement.
Ten years ago, even three years ago when I retired, my self deception about my superior EQ would have allowed me to assert that I was earnestly and completely patient centered and deeply respectful of all patients. I would have been offended if someone had suggested otherwise. Ditto on how I thought I was perceived by close colleagues. I was right about how some patients and colleagues reacted to me, but not aware of the fact that some people were not so sure that my self interests were not the first order of my business. I was secure in my opinion that some patients were not engaged and that some colleagues had an agenda that was not exactly aligned with mine, even though we could all salute the Triple Aim and describe quality care as being patient centered, safe, timely, efficient, effective and equitable.
As a physician who wanted to be trusted, I did not really understand or sense accurately when and how I failed to connect. What I am offering for your consideration is whether or not there are many health professionals who, like me, are often not completely aware of how they are perceived. Despite talking about universal access to healthcare for seventy five years and focusing on quality for a quarter century and having the Triple Aim as a clearly defined goal for almost ten years, is it possible that our continuing problem with the high cost of care has something to do with our industry’s collective lack of EQ? Do we fail see ourselves as our patients see us or understand the issues as they see them?
A few years ago I got caught up in the transcendent African theological concept of Ubuntu. Six months ago Ubuntu was central to one of these letters and to the posting on strategyhealthcare.com. In that post I quoted Desmond Tutu:
Bishop Tutu… Ubuntu is the essence of being a person. It means that we are people through other people. We can’t be fully human alone. We are made for interdependence, we are made for family. Indeed, my humanity is caught up in your humanity, and when your humanity is enhanced mine is enhanced as well. Likewise, when you are dehumanized, inexorably, I am dehumanized as well. As an individual, when you have Ubuntu, you embrace others. You are generous, compassionate. If the world had more Ubuntu, we would not have war. We would not have this huge gap between the rich and the poor…This is God’s dream.
Discussions of Ubuntu often make references to the Jewish theologian Martin Buber and his concept of “I-It” versus “I-Thou”. A South African theologian, Selaelo T. Kgatla, has emphasized this point in an article published earlier this year:
The concept of Ubuntu is known intuitively rather than reflectively as Martin Buber argued in his work Transcendence and Relationality (1958). According to Martin Buber, transcendent experience which he calls ‘pure experience’ (Ubuntu in an African context) is based on encounter but not reflective thought but on active engagement. Ubuntu requires full participation in the life of the other; participatory experience rather than reflective experience. The emphasis in Ubuntu is on the betweenness that relate people to each other in mutuality. This betweenness, as first coined by Martin Buber, calls love as expressed in human relationships and experience. Ubuntu requires humility, an act that requires the ego to deny its impetus to establish itself as primary and as the centre of human experience; overcoming the ego to establish foundational relationship with the other as used by Buber.
That may be a little heavy but I think that he is explaining that meaning in our lives, and I would add in our professional lives, arises from getting involved with others. As humans we feel most fulfilled when we are “present” and actively involved with others in community. It is best when we are aware and focused on our communities and those to whom we have professional responsibilities. We must be aware of the feelings of others at a level that allows us to fully understand how what we are doing may or may not be working to help them. That level of awareness would allow us to see that the high cost of healthcare is a problem that our communities. Our communities wish we would address the cost of healthcare more effectively because the cost is killing so many and causing healthcare to fail many that it does not kill.
I was recently delighted to read a column in the New York Times entitled “Read Buber, Not the Polls!” by David Brooks that was focused on our national malaise.
Brooks hooks the reader with the first line:
If America were a marriage we’d need therapy.
A little further down the page he introduces Martin Buber as the appropriate therapist for us and explains the I-It relationships and I-Thou relationships:
…I-It relationships are truncated versions of what should be deep relationships. You’re with a friend, colleague, spouse or neighbor, but you’re not really bringing your whole self to that encounter. You’re fearful, closed or withdrawn — objectifying her, talking at her, offering only a shallow piece of yourself and seeing only the shallow piece of her.
I-Thou relationships, on the other hand, are personal, direct, dialogical — nothing is held back. A Thou relationship exists when two or more people are totally immersed in their situation, when deep calls to deep, when they are offering up themselves and embracing the other in some total, unselfconscious way, when they are involved in “mutual animated describing.”
Brooks goes on to say that a doctor has an I-It relationship with a patient when he treats the patient like a broken machine. A doctor is in an I-Thou relationship when she sees the patient as a person like herself and responds to her pain and suffering because of their shared humanity. Are we as a profession, and often as individuals, in I-It relationships with our patients and our communities?
Brooks stresses the importance of the I-Thou relationship :
…Buber argued that it’s nonsensical to think of the self in isolation. The I only exists in relation to some other.
My point is that as healthcare professionals and as a profession or industry we have meaning when we are in relationship to the “other” of all patients and our communities.
I like the way Brooks ends his piece.
Today, America is certainly awash in distrust. So many people tell stories of betrayal. So many leaders …model combativeness, isolation and distrust… the only way we get beyond depressing years like this one is at the level of intimacy: if Americans reconnect with the living center of the national story and ….rebuild Thous at every level.
Those words apply to healthcare and our quest for the Triple Aim. As I look back on my years of practice and attempts at organizational leadership, I wonder how often I was approaching the moment with an I-It mindset. That feels like a professional concern that transcends EQ. Being in the moment and mindful is a step forward, but I believe striving for an I-Thou relationship with patients, colleagues and community would be even better and more fulfilling way to speed us toward better health no matter what happens in Washington.
