The Butterfly Effect

Rory Gilbert, M.Ed., SPHR, SHRM-SCP on July 16, 2018

I was a philosophy major as an undergraduate and for my senior thesis I found myself wrestling with determinism v. free will. Are we on a pre-planned course? Do we have the capacity to change the world? My answer at the time was that everything is in effect determined by all that has come before, that we are on a track rolling toward our destiny, but we still must choose our course based on what we know and feel at the time to be right, and that is, in effect, free will.
So, who would think some xx years later, I’d read a small statement that brought me back to those heady college days.

Butterfly Effect
The scientific theory that a single occurrence,
no matter how small,
can change the course of the universe
forever.

This concept emerges from chaos theory[i] and challenges my notion of determinism.  Chaos theory proposes that in complex systems, small changes can have unpredicted effects.  That is why weather prediction, while getting more accurate, still remains a matter of probabilities… or predicting the stock market, election results, etc. And interestingly, in research, we know that just having an observer can influence the outcome.
So, this got me to thinking about my coaching and organizational development work.  I thought about DiSC™ styles. DiSC™ identifies four different ways healthy people approach the world (in various combinations) as ways we can better understand ourselves and others. One of the key elements it explores is sense of control. Some of us tend to think we control our world (let me lead) and others that we must respond to our world (let me prepare).
Those that think we control our world tend to be action oriented, decisive and fast-paced.  I associated that with the concept of free-will, creating one’s destiny. Those that think we must respond to what the world hands us tend to be more analytical, deliberative and more moderate-paced. I associated that with the concept of determinism, having to accept what happens.
The Butterfly effect suggests that we all have impact whether we are aware of it or not – that how I act or even if I act is a choice that impacts my world. I sometimes feel very small, unimportant and of little value. I can convince myself that whether I take action, donate to a cause, speak up or stand up will make little difference. But the Butterfly Effect reminds me that I what I do or don’t do makes a difference.  We are all interconnected, and our actions matter even when we don’t know it.
Heraclitus stated, “The only constant is change.” This was true some 2500 years ago, and is even more so, now. Our world is complex, rapidly changing, and only somewhat predictable…so let me do as much as I can to prepare (responding to the world) and then step up (creating our destiny) as I need to.
How do I prepare? I keep current on what is happening in my world, in my sphere of influence.  I consider possibilities and probabilities and what resources and actions might be required. I also consider my values, my priorities and sense of purpose so that I base my course of action on what is important.
How do I step up and lead? I use all my preparation to allow thoughtful and meaningful decisions in the time frame that is required.  I avoid knee jerk reactions or being immobilized because I was not prepared.
And I whether I tend to be more action or preparation oriented, I find trusted people in my world who complement my strengths and skills and join me in actions and decisions…without always knowing the results of our actions and decisions. And I accept the fact that the end results may not be what I thought they would be.
In my first career, I was a youth and family counselor.  I provided prevention and early intervention work to middle school students. I met with a group of 7th grade girls to help them adjust to adolescence and middle school. One of the girls never spoke in the group and I wondered why she kept coming and doubted anything we did was making a difference.  Some four years later, I was walking down the halls of a high school when a young woman approached me and called me by name.  It was this same young woman, now a confident and successful junior in high school.  I told her that I was surprised she recognized me and she said something I will never forgot. “I remember everyone who tried to help me.”
So, consider the Butterfly Effect in human behavior as well as in the physical world. Every day we make choices about where we put our energy, how we behave, what we do…and what we think.  We make a difference in our world mindfully or heedlessly.
On November 9th, Thunderbird Leadership will be sponsoring our 12th Annual Leadership Summit, Being on Purpose: Small Enough to Manage, Big Enough to Matter. We’ll be exploring how we can intentionally impact our world from our own little spot on our own little planet.  For more information go to: http://thunderbirdleadership.com/event/12th-annual-leadership-summit-being-on-purpose
“Wherever you are, be there totally. If you find your here and now intolerable and it makes you unhappy, you have three options: remove yourself from the situation, change it, or accept it totally. If you want to take responsibility for your life, you must choose one of those three options, and you must choose now. Then accept the consequences.”  – Eckhart Tolle
[i] For a brief introduction to the Butterfly Effect and Chaos Theory check out: https://www.americanscientist.org/article/understanding-the-butterfly-effect
https://www.forbes.com/sites/startswithabang/2018/02/13/chaos-theory-the-butterfly-effect-and-the-computer-glitch-that-started-it-all/#58b6d90269f6
 
 

Why is Accountability So Hard?

Rory Gilbert, M.Ed., SPHR, SHRM-SCP on March 15, 2018

What is the number one frustration for people managers?  In my coaching work, I hear repeatedly that it is getting people to do what we expect them to do.  Whether it is how they prioritize, the process they use to get results or the actual tasks they do, I repeatedly hear folks sigh, “If I want it done right, I have to do it myself!”
So why can’t we get people to do what we want, when we want it, how we want it?  Here are a few observations:
1) The most important thing we can do is be clear about our expectations. Whether we are working with a brand-new employee or a long term established employee, we need to take time to be sure we are clear on priorities, goals and processes and how the employee’s work links to the organizational mission.
I remember speaking with an executive who prided himself on never providing feedback or assessments to his “good” employees. “I only do evaluations when people are not performing well,” he said.  He went on to explain that they received their job description when they came in and they should know what to do.
Can we really expect a job description to cover all our expectations?  Don’t things change over time?  Even with high level employees, is it possible that what they think is important is not what we think is important?
While there is a lot of discussion about the pros and cons of annual reviews, there is no doubt that setting expectations, updating them and providing feedback regularly is critical to performance success.
2) And then, whether we set expectations or not, our next challenge is how we communicate what we want. We are totally clear in our own heads – I know I make sense to myself. However, I have discovered that what I think I thought I said is not what other people hear.  If you want to be sure you are on the same page, you need to summarize what you’ve discussed and agreed to…preferably in writing.  How does this play out?

  • On the fly comments are not captured.
    For example, I am walking with someone to a meeting and say something like, “and I’d like it if you did x, y or z…”  I remember I said it. I see it as a directive.  Did the person I related it to write it down? Did we discuss a due date? Did we prioritize? What are the chances this will be retained after the meeting?  Would I remember it if the tables were turned? Be careful that we don’t think we are so important that our “in passing thought” will be retained.
  • Weekly meetings end in confusion.
    You have a typical one-hour meeting with your direct report or your team and discuss a dozen different items. Time is up and off you go, each of you totally clear in your own minds about what was important, the priorities, strategies and time lines.

Stop the meeting with ten minutes to go and review what you have discussed. Ask your direct report(s) to summarize…that way you will know what they heard and plan to do.  This is a great way to identify misunderstandings, ideas that were dropped and disagreements with the plan of action. You may discover that you need more than ten minutes for the summary.
Often, it is not until the review that you discover that someone is not buying in to an action item.  They were silent during the meeting because they were still thinking about it and/or disagreed but didn’t want to bring it up, but now that you mention it again and are defining it as a priority…well it is time to speak up because it isn’t going to disappear.
How often have you raised an item at a meeting and there is no response? We usually assume that everyone is on board, but the truth is, silence is sometimes cloaking discomfort, dissatisfaction or confusion. One of my favorite concepts from Patrick Lencioni is to assume silence is disagreement. Invite affirmative commitment to a plan before you think you are ready to go forward.
Ultimately, summary reviews should include priorities, responsibilities, timelines and check-in dates.  And, how will you document these? Format can range from a white board, easel page, spreadsheet or project management program depending on your team, the complexity of the projects and preferred workstyles.  If it is not documented, it isn’t going to happen!

  • Direct requests are not followed up on.
    This is an interesting item.  I am amazed at how clearly we think we are saying things (remember how clear we are in our own heads?) and yet we are often vague, noncommittal and ultimately unclear in what we want.  I’ve invited myself into meetings with directors and managers who are beside themselves with frustration because they do not get the results they want from their direct requests.  I’ve heard some of the following:
  1. Would you be willing to do x? (and then they are surprised when the employee declines to do x.)
  2. It would be helpful if you could do x. (Employee hears, a “nice to do” not a “have to do.”)
  3. I’d like you do x when you have the time. (no time line, no importance, no priority…are you surprised it isn’t done?)
  4. What do you think about doing x? (interesting idea…oh, do you mean me?)

And in all of these cases, the leader/manager/supervisor thinks they have made a direct request. I’ve come up with two possible reasons why requests are framed this way…and would like to hear your thoughts.

  • The leader/manager/supervisor does not want to come across as too bossy or demanding. This can often be the case when someone was promoted from within the ranks.  It is also possible when there are differences in social identity where there is a hierarchical imbalance.  (E.g. age – younger boss to older employee; gender – female boss to male employee.)  A lot of times these changes in how requests are made are not even conscious.
  • The leader/manager/supervisor thinks they are so important that they expect their employees to jump at their every wish. We shouldn’t have to write it down or review it, they should just do it.  I am too busy to take the time.
  • Why else? Cultural differences? Personality differences?

3) And finally, the biggest challenge of all is follow-up. I’ve heard over and over again, “who is going to hold people accountable?” The answer is…you…by setting deadlines, requiring updates, expecting people to inform you ahead of time if they are facing a problem and/or are not going to be able to deliver on-time.
I spoke to an employee recently who was given an assignment a year ago. He’s been asked several times how he’s doing on completing it.  He says, he’s working on it.  His manager knows he should have it done by now but hasn’t said much more about it. The truth is, the employee has been overwhelmed by the task and has avoided it by keeping busy with other projects. How important is the project if it has been drifting along for a year?
We don’t have to be mean and nasty to get results. In a nutshell, we need to:

  • Set clear expectations that include priorities and expected outcomes.
  • Be mindful of when and how we frame requests.
    • “On the fly” requests get lost.
    • Casual requests may sound like suggestions or low priority.
  • Summarize action items from meetings to ensure timelines, responsibilities and priorities.
  • Link requests to the goals and purpose of the organization. We know that people are able to embrace their work more effective when they can connect the dots to purpose and meaning.
  • Follow-up in a timely manner. If it isn’t important to you, why will it be important to anyone else?

Lessons Learned

Rory Gilbert, M.Ed., SPHR, SHRM-SCP on December 15, 2017

As we approach the end of the year, it is a wonderful time to reflect and take stock on what we’ve learned. Some learnings are easy, many come through unexpected challenges.  We’ve asked our consultant team to share some of the lessons that have emerged for them this year, and hope they provide you with insights that you will find helpful.
Experience Fun!
What I’ve settled on is as much something I aspire to, as something I’ve learned. Here it is. Life may turn out to be shorter than we had imagined, but one thing is for sure – Life is definitely better than we could have ever imagined. We have all been richly blessed. There’s so much joy and beauty available to us every day, and so much fun to be had in almost every moment. I’ve learned that I want to be more lighthearted and playful, and really experience all the fun that’s available to us. This is a bit of a reach for a serious, hard-working German girl like me, so if you see me off track, please remind me to lighten up.
Clean House
One of my lessons focuses on my 2017 year of “cleaning house” – both literally and figuratively.  Sold my condo, said goodbye to being Condo Board president for 15 plus years, now sharing a tiny little house with my sweetie, gave away more than half of my furniture…. and simplified.  The smallness is comforting, the shedding of “stuff” allowing me to breathe more freely.  Marie Kondo’s book, “The life-changing magic of tidying up” was inspiring.   Admittedly, progress on eliminating “keepsakes” and books/documents (some of which are still sitting in the basement…old family photographs (half of the faces not identifiable!), the syllabus for a class I “might” teach, past work creations) are slower-going, as Kondo suggests they can be – but my progress is real, shedding a light on how “tidying up” has freed (and continues to free) my mind and my soul.
Be Present!
I have come to carry 3 words with me this year that have meant A LOT! Be. Here. Now. They point me to the understanding that the present is all I have, and I dare not waste this precious resource by micro-planning every little step of an anticipated experience, nor replaying (and often affirming my own righteousness in) an unpleasant past experience. “Be here now”, has helped me stop to breathe, to stop the flow of words in my head, and to listen to the sound of my heart, my breath, or the silence inside me. Quieting my mind has become a practice I look forward to every morning. . . I am an early riser and I love to watch dawn color the sky. Being here now, in the present, is also directly linked to presence, which is the very best part of myself that I can give to another. Or to the sunrise.
Manage Anger and Frustration
I have been working hard to control my anger and frustration when situations arise. Since I am the only person that knows when anger is building, I have learned to recognize the danger signs when they begin. I can choose how to react in a situation and just because my first instinct is to become angry doesn’t mean it is the correct response.  I realize that when I start to get angry I need to stop what I am doing and breathe deeply. This interrupts my angry thoughts and helps put me back on a more positive path. Also, if I imagine how I look and behave when I am angry I probably would not want to be around someone like that.  A great person once shared that if I “Pause, find Peace and Pray, I can’t but help create an Attitude of Gratitude.”
Redefine Time  – this came up twice! As consultants, we are not bound by the typical 9 – 5 clock of an employee. Does this impact how we see time?
I have been challenging my misconception about time. . . the clock is useful for some things, but not as a way to experience and evaluate my life. Have I done everything I wanted to do before I turned a certain age? Did I get everything finished that I wanted to do on Friday? What crazy pressures! Because my life is no longer constrained by the clock, I am experimenting with the natural rhythms and ebb and flow of things . . .like my energy, the need to balance work, play and rest, the times for eating.
One lesson for me this year is to be mindful of how I spend my time. I am aware that time is a finite commodity. Am I doing what I want to be doing? What I need to be doing? Or am I just doing?  I am working at being more aware of the choices I make in how I spend my time both at work, in volunteer capacities and at leisure. Even when all I am doing is playing spider solitaire on my cell phone, I can give myself permission to be in a restful state — almost meditative — accepting that down time is a reasonable choice sometimes rather than berating myself about “wasting time.”  And I can make intentional decisions about the work I choose to do — having fun, finding meaning and earning money!  Rather than feeling obligated or compelled to work at things that are stressful and demotivating.  (Yes, I am fortunate to be able to choose this.) And I am finding that being is a valuable way to spend my time — being with family and friends, being outdoors, and being with my colleagues – with you all … who provide me with energy, perspective and support.
See Beyond our Thoughts
I’d say the most important lesson I’ve learned this year is to realize that I don’t need to believe everything I think or anything that anyone else thinks. I grew up in a household that was incredibly loving, full of extended family members who created a safe space for me and my cousins to play and laugh. It was also a household where “father knows Best” and everyone else’s thoughts came in second or third or nowhere at all.
So, in college, I was suddenly in a place where everyone wanted to know what I thought. Thinking was encouraged. And I got to voraciously read and discover other thinkers thorough-out history. I got to organize my thoughts around theories that inspired me and writers who were so articulate in discussing and defending their thoughts. I had many many journals which I used to express my thoughts about everything. You could say I became enamored by my own thoughts. And eventually gained expertise in helping myself and others explore their thought patterns, understand their origins, determine whether they were limiting beliefs and learn to shift or change them to create better results.
So, you can imagine my surprise, during my final year of my doctoral program, as I’m finishing up a 400+ page dissertation, to realize that I don’t need to believe what I think and that I don’t need to even heal my thoughts or shift my thoughts or have anything to do with my thoughts.  And that there’s a space beyond thought, a place of Presence and stillness and nothingness that holds more beauty, more potential, more joy than any of my thoughts or other people’s thoughts could ever imagine or express.
This experience is allowing me to relax into being “ordinary” and free to be with other people’s thoughts without the need to be on the defense or offense of anything. It’s bringing into my life a sense of groundedness and compassion and curiosity and insights the likes of which I have never experienced before.
Accept Ourselves as We Are
This year has been a year of unfolding awareness around the passage of time – of shifts in the way I hold myself in relationship to the world, an enlarging awareness that my presence – our presence – on the earth is but temporary, and the startling reality that things I never expected have planted themselves firmly in the landscape of my life.
I have been toying with existential questions – why are we here, what purpose does any one individual have, what is the meaning of this thing we call life?  I invited myself to lift and lift and lift above the details of the daily human experience and really try to SEE what made sense about life and living.  What a surprise when I realized that my presence on this earth – from a larger perspective – is absolutely and utterly insignificant!  Creation will not care if I eat kale or write bad music or am good at cleaning the kitchen.  I will not invent the light bulb or paint the Sistine Chapel or have my name attached to some doctrine.  The details of my daily life are inconsequential, and I am not required to place any kind of signature whatsoever on human history.
Paradoxically, the moment I had that realization was the same moment in which I understood fully that it is my own unique way of being, instead of my way of doing, that contributes to all of creation in a way that is meaningful and sustains the goodness that surrounds us always, whether we know it or not.  It was the moment in which I knew, without doubt, that expanding in love and kindness, compassion and generosity, caring and integrity, honesty and grace and offering THAT to the world (and to myself) is truly the only job I have as a human being.  Less doing, more Being!
So, let time fly or drag or whatever it does today or tomorrow.  My intention is to love every moment of this glorious, mysterious, messy, confusing gift called life – and to graciously forgive myself if I slip now and then!  To paraphrase one of my favorite sayings – when the tide rises ALL boats rise!!
And we invite you to share your lessons learned or your aspirations for next year with us as well in the spirit of giving that frames this time of year. Here’s a start on 2018. . . 
Study Sound
Next year I want to study sound, and the effect it has on our lives. . . the good, the bad, and the ugly. When friends from a big city come to visit me in rural Arizona, they consistently say, in a reverent way, “It is so quiet here!” The effect of abusive noise, including those noises in our heads, and the benefit of beautiful sounds (like Joyce’s harp at the Summit) are topics I want to explore.
Thank you to all our contributors: Julie Wechsler, Jill Bachman, Michael Cavanaugh, Mary Lockhart, Rory Gilbert, Noushin Bayat, Carla Rotering

Reflections on Being of Service: Leadership Summit 2017

Rory Gilbert, M.Ed., SPHR, SHRM-SCP on November 15, 2017

Thunderbird Leadership held its 11th Leadership Summit on Friday, November 10th. When the planning team convened, they discussed its proximity to Veterans Day and we were all taken by the notion of service. What does service mean? How do we serve? Who benefits? The day evolved into exploring notions of service, mercy and compassion…recognizing potential avenues to impact others as well as the need to care for ourselves so we have the genuine capacity to serve.

Dr. Gladys McGarey was the keynote speaker. She will be celebrating her 97th birthday this month and shared the story of her life in decades starting with her early childhood in northern India where her parents were medical missionaries. Clearly, she was born to service. Her story depicted a life of courage, seeking truth, and finding ways to bring healthful living to people throughout the world. We were struck by her challenge to change the medical model from “a war against disease,” to one that seeks life and balance – moving from fear to love. Her story was spellbinding and the consensus was that we could have listened to her all day!

How often do we take time to truly listen to others’ stories? Each of us has a tale to tell of how we arrived at this moment in time.

Our next speakers were Dr. Gladys’ extended family – who spoke about well-being. Julie Wechsler, a certified executive and well-being coach, shared factors that matter for overall well-being in our lives and differentiated surviving and thriving. She integrated how service was a critical part of thriving and introduced her daughter-in-law, Ashley, to share what service has meant to her. Ashley told her heartfelt story of being a “Big” for Big Brothers, Big Sisters and how it has profoundly changed her life. Ashley has been a Big Sister to the same girl for seven years…their families now entwine even more with connections, love and honor with Ashley’s Little Sister’s brother and sister.

The message was loud and clear – when we give, we receive.

Dr. Carla Rotering talked about mercy and forgiveness. Her gentle, thoughtful and deep remarks challenged us to “radical mercy,” to have compassion for ourselves and others without evaluating who “deserves” it. How do we navigate the world if we believe people are doing the best that they can? How do we treat ourselves if we believe that about ourselves? What is the impact on the world? Dr. Rotering completed her presentation with a poem she wrote, “The Reckoning,” that left us speechless – a journey from doubt and pain, to compassion and self-acceptance.

“And the tenderness of your true heart rises up to meet you
At the higher place to which you have come
And the shroud that has bound the secrets to your spirit for so long
Simply falls away.”
Carla Rotering, 2002

So, here we are at a Leadership Summit about service and we are being asked to take care of ourselves – recognizing that we cannot genuinely serve others if our own self is untended, uncared for. I am reminded of a concept from Dr. Brene Brown who stated that the people who are the most compassionate have the best boundaries. They know themselves, care for themselves and act from the heart, from love and “radical mercy,” not from obligation.

And the truth is, we can all feel that difference, can’t we?

In the afternoon, we heard from Katie Owens and her story of resilience, depicting how we can move from disappointment and rejection to new opportunities and possibilities. Once again, the message is about inner strength making space for genuine service.

“Out beyond stories of right-doing and wrong-doing, there is a field, I’ll meet you there…”  Rumi

And finally, Mary Lockhart, Noushin Bayat and I finished the day looking at how the messages we tell ourselves impact our ability to act, to serve. Back to stories once again! We challenged ourselves and our participants to differentiate fact from fiction, observation from interpretation. We asked participants to “turn to wonder” when things get difficult, turning away from, “I don’t,” “I can’t,” “I never,” and opening possibilities for new stories and new perspectives, concluding with a quote from Viktor Frankl,

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

And then, the day was over. Our heads were filled with messages of care, compassion and passion for ourselves and for others…to see the world in a new way and to find our place of impact, not to wait for the right time, but to make today the right time.

P.S. – There were so many fabulous contributors to the day that enhanced the experience of the Summit for everyone. Check our photo gallery to see the support of our sponsors, imagine the day graced by harpist Joyce Beukers, massage therapist Heather Paslay and graphic documentarian Stephanie Levine. A Silent Auction inspired generous giving which netted well over $2000. Every participant had a chance to submit “their” charity of choice for the Silent Auction proceeds, and this year, the Humane Society was the lucky recipient. We hope you will be able to join us next year!

Warriors for the Human Spirit

Kathy Scott on November 1, 2017

I had the pleasure of participating in the planning and presentation of a Leadership Intensive for Nurse Leaders October 19-21. The attendees arrived on a Thursday evening, weary from their work week and a bit uncomfortable in a new environment with strangers. We did our best to help them feel comfortable and pampered in a beautiful, fall-desert setting with beautiful gardens and accommodations.

This was a first-class offering with expert speakers from around the country; each integrating their expertise, insight and wisdom into their presentations and case studies. I realized as I listened that each of the speakers was also a warrior for the human spirit, approaching their work with gentleness, decency and bravery. They shared stories of creating strategies that would move their area of influence forward over the long haul. They focused their passion and energy on what was possible, albeit often difficult and/or unpopular but needed, to accomplish the vision and create healthier environments.

I watched the weary-leader participants perk up, sit up, get engaged in the discussions. We provided them with new tools that would help them see and shape their organizations in new ways. We also shared our view of the needed leadership attributes for today’s world of disruption and chaos, in order to influence more effectively, achieve personal success, healthier environments and sustainable results. Each attendee walked away with the beginnings of a plan to address a difficult problem they were dealing with. And they left with a network of new colleagues and friends with whom they will connect over the months to come.

I too left energized, knowing deep inside that we are preparing the next generation of leaders to lead from a new place. This place acknowledges the importance of nurturing the human spirit while leading with competence in today’s dynamic and complex systems.

Kathy Scott, RN, PhD, FACHE

What Difference Does It Make?

Rory Gilbert, M.Ed., SPHR, SHRM-SCP on July 17, 2017

On Christmas Day a few years ago, while juggling suitcases at the airport, I hooked one on a pole, tripped over the wheel, and went skidding across the floor in my best belly flop position. It was quite dramatic. In addition to the acute embarrassment, I had a fabulous rug burn on my hand and jammed my shoulder as I caught myself in the fall.

A few weeks later, my shoulder was still out of whack. My weight trainer and my chiropractor (both women) recommended physical therapy. I went to my PCP (a man) to get an order for physical therapy. He checked me out, deemed it a soft tissue injury and said physical therapy was unnecessary because it would heal on its own in 6 to 12 months. I accepted what he said and dealt with the discomfort while continuing my workout regimen and not sleeping on that side. However, I wondered if I had been a 40 year old man, would my doctor have been as quick to expect me to wait it out for a year?

Currently, the health care industry is focusing a great deal of energy on the patient experience with training, assessment and whole departments dedicated to the provider-patient relationship and communication. As a patient, I am on the outside looking in and wondering how much attention is given to unconscious beliefs in these programs?

In 2003, the Institute of Medicine produced a critical publication about health care entitled “Unequal Treatment”. The report concluded that “unrecognized bias against members of a social group, such as racial or ethnic minorities, may affect communication or the care offered to those individuals.” (Blair et.al., p. 71) It stated that people experienced differences in the quality of their healthcare based on their social identities: race, ethnicity, age, gender, socio-economic status, insurance status, and sexual orientation. (Blair et.al., p. 71)

Further research indicates that differences in the quality of care are also associated with conditions such as mental health issues, obesity and drug use. (FitzGerald, p. 13)

Since 2003, some of healthcare’s most turbulent issues (revolutionary medical interventions, increases in pharmaceutical costs, the controversy over the Affordable Care Act) have influenced expectations and outcomes for the industry. Is healthcare a right or a privilege? Should health and longevity be based on one’s financial or social status? How should healthcare be allocated and compensated? These public policy issues continue to be debated and at this time, the outcomes are not known.

What has not changed fourteen years later is the fact that who we are impacts the care we receive. Numerous studies since then reaffirm that implicit or unconscious beliefs impacts our relationships with our caregivers, the quality of our communication, and the diagnoses and treatments we receive. (The Joint Commission, p. 1)

How does this play out? Examples from the research include impacts on three areas:

Communication and relationship:

  • Unconscious attitudes can negatively influence interpersonal interactions, especially with individuals whose backgrounds differ from our own–often in ways that are subtle and difficult to recognize. Such interactions may contribute to a lack of trust and commitment on the part of the patient, leading to poor adherence. (Blair et. al., p. 73)
  • Besides influencing judgments, unconscious beliefs show up in our non-verbal behavior towards others, such as frequency of eye contact and physical proximity. Unconscious beliefs explain a potential difference between what a person explicitly believes and wants to do (e.g. treat everyone equally) and the hidden influence of negative implicit associations on one’s thoughts and actions. (FitzGerald & Hurst)
  • Stereotype threat may impair patient-clinician communication, reduce self-efficacy, and increase mistrust. (Blair et.al., p. 75)

Diagnosis and treatment:

  • Non-white patients receive fewer cardiovascular interventions and fewer renal transplants.
  • Black women are more likely to die after being diagnosed with breast cancer.
  • Non-white patients are less likely to be prescribed pain medications.
  • Black men are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have testicle(s) removed.
  • Patients of color are more likely to be blamed for being too passive about their health care. (The Joint Commission, citing van Ryn)

Patient behavior:

A 2011 study conducted by van Ryn et al. concludes that racism can interact with cognitive tendencies to affect clinicians’ behavior and decisions and in turn, patient behavior and decisions, such as higher treatment dropout, lower participation in screening, avoidance of health care, delays in seeking help and filling prescriptions, and lower ratings of health care quality.

While there is evidence that conscious or explicit bias has declined significantly over the past 50 years, there is no evidence of change in unconscious or implicit beliefs. This is profoundly disturbing for people who express, believe and desire to treat all people equally. (Blair et. al.)

Call to Action

We know that most health care providers truly want the best for their patients, but without intentional effort, providers may be unconsciously short-changing their patients. . . and patients may also be complicit in risking their own outcomes. (Blair, et.al, p. 74) Essentially, we are in a relationship where one party’s behavior affects the other, and vice versa.

This research has been growing for the past fourteen years. There are some valiant efforts to change things in pockets of the health care industry. So how can we expand the message and reach all providers and patients in a comprehensive and effective way?

  • The first thing to do is acknowledge that differences in health care access and outcomes are real and that we all participate in maintaining them.
  • Then we need to identify those areas we can influence. Certainly, this is a time where policy and legislation is at the forefront of our attention…so yes, call, write, lobby, do what you can and what you believe to move our nation forward, so that we can have equitable and effective health care for all.
  • And finally, we need to look at ourselves and identify effective ways to challenge our own preconceptions so that we provide and receive the best possible health care.

Receive you ask? Yes, receive. I had a responsibility in that partnership too. Why didn’t I ask my doctor why he thought it was okay for me to be uncomfortable for a year? Yes, I did assume that he was treating me like a little old lady and that my physical activity didn’t matter. I did not speak up or take the time to challenge my assumptions or his. I was complicit in maintaining disparate treatment – even if the answer to my question was that he would have treated a 40 year old man the same way. I was complicit because our relationship was damaged. I lost trust in him and discounted his investment in me. He did not have an opportunity to reflect on whether, in fact, he was making incorrect assumptions about me – and “little old ladies” like me.

Although research has not yet identified proven strategies for providers or patients, there are a number of promising approaches that have been found to reduce unconscious beliefs. Here are some recommendations that appear repeatedly in the literature. (van Ryn, Blair et.al., FitzGerald & Hurst)

  1. Practice perspective taking — how might the other person feel? What might they be thinking?
  2. Remember that we are all human and all individuals. Providers need to see their patients as individuals. Patients need to recognize that their providers are human and imperfect.
  3. Develop empathy – listen to the feelings behind the words, observe non-verbal cues – and then address what you see and hear.
  4. Increase partnership building and see the provider-patient relationship as a partnership. When we are in it together, we consider the other as part of our group, which increases caring, empathy and trust. When we are in a partnership, we can and must speak up, question assumptions, and provide feedback.
  5. Counter assumptions. This action has been proven to have the strongest evidence for change. Decrease negative preconceived signals and seek out and attend to information and images that are contrary to the assumptions. This takes intentional effort!! Professor Margaret Whitehead, head of the World Health Organization (WHO) Collaborating Centre for Policy Research on Social Determinants of Health states that, “Once learned, stereotypes and prejudices resist change, even when evidence fails to support them or points to the contrary. People will embrace anecdotes that reinforce their biases, but disregard experience that contradicts them.” (cited in Blair et.al., p. 1)
  6. Increase positive interactions with people of difference.
  7. Manage stress levels and cognitive load. When we are overloaded and in high stress situations, we revert back to preconceived notions in order to reduce mental demand necessary to cope.

If we truly want to improve the patient experience (as providers and as patients), we need to be serious about building genuine relationships. This requires trust, honesty, and recognition of our human frailties. It requires us to be mindful of our preconceptions and help each other challenge them. How else will we become conscious of that which is unconscious? How else will we ensure the best possible care?

References:

Blair, I., Steiner, J., & Havranek, E. (Spring 2011). Unconscious (Implicit) Bias and Health Disparities: Where do we go from here? The Permanente Journal, Volume 15 No. 2. retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140753/

The Joint Commission, Division of Health Care Improvement, (2016). Implicit Bias in Healthcare, Quick Safety Issue 23. Retrieved from

https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf

FitzGerald, C. & Hurst, A. (2017). Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18:19. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333436

van Rynd, M. 2015. Unconscious Bias in Healthcare. APHA Webinar on Unequal Treatment: Disparities in Access, Quality and Care. Retrieved from

https://www.apha.org/~/media/files/pdf/webinars/racism_webinar3_part2.ashx

Smedley, B., Stith, A. and Nelson, A. Eds, (2003). Unequal Treatment, Confronting Racial and Ethnic Disparities in Healthcare. National Academies Press. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25032386

Unmet Expectations, Created in Isolation?

Carla J. Rotering, MD, M.A. on June 21, 2017

We sat in the driveway, my sister and I, each peering out our opposite windows, each wrapped in the disappointing sense that we had failed one another while the uncaring car simply idled in the background. “We agreed on this” my sister said, still without turning her face toward me. “No, you told me how we were going to do this, and I said nothing” was my response as I also turned toward my own window. Somehow, she thought my silence meant I agreed. Somehow I thought my silence would indicate I did not agree. Just as the view was different for each of us through our opposing windows, we had an entirely different and singular understanding of what we had agreed on. The spoken and unspoken expectations we had of one another had dragged us unwittingly toward this predictable moment of upset and disappointment.
We carry all kinds of expectations into our days – expectations about relationships, performance, quality standards, purchases – nearly anything we encounter in the details of our personal and professional lives. What makes expectations challenging is that they are unilateral, often unexplored, and are frequently made known in either vague or authoritative ways – or both. Most people resent expectations – especially authoritative and unreasonable expectations – although they may try in earnest to meet them. On the other hand, most people like to keep agreements that are co-authored – to have the chance to agree to what you can count on from them.
Take a seat in any break room, boardroom, meeting room, or bedroom and you are sure to hear complaints, the drone of disappointment, and the bitterness of having been let down. You can hear the utter disbelief that the world didn’t come through for you or me (or Bobby McGee) in the way that it was supposed to, the way that it should have – the way that it would have if anyone cared enough! We might hear something like “he really let me down” or “she should have known better” or “I can’t count on anyone but myself” or, perhaps the most poignant of all, “If he REALLY loved me, he’d know. I shouldn’t have to ask.” When that is the conversation, we are living in the realm of unmet spoken or unspoken expectations.
And when we operate in the realm of expectations – when we engage in our relationships expecting that people will behave the way we want them to, want exactly what we want, understand in tandem with how we see the world, we set the stage for one of two outcomes. We will either feel disappointed or we will feel nothing at all. If others fail to meet our expectations, we will feel upset and disappointed. If others actually meet our expectations, we may not feel anything at all, because that is simply, without celebration, what we expected. It is, after all, the very least they can do!
Disappointment can sink you like a stone and yet, with a simple rearrangement in our thinking, disappointment can be significantly minimized if not eliminated.
What if our complaints could be turned into requests? When we first notice we are disappointed and hosting a complaint we can choose to gain a little altitude and ask ourselves if we have a request of that person. Is there something inside the complaint itself that actually assists us in recognizing what it is that we want or need to bring about success and dissipate the potential for disappointment? What if we simply, then, made that request?
Of course, making a request does not assure an agreement will be established. It does, however, open the possibility of co-authoring a strong, solid agreement that reflects everyone’s voice. Making a request is bold, and courageous, and an act of integrity. It is the first step in negotiating an agreement that brings all the invisible barriers and potential to the table.
But what if a request is made, and the answer to the question “can you agree to this” is no? That’s when we can ask questions that can point us toward agreement:

  • What are you willing to do, if it isn’t this?
  • Here’s what you can count on from me. What can I count on from you?
  • What would you need from me (the organization) to support you in an agreement like this?
  • What do you think we would need to do to make this even better?
  • What might get in the way of us keeping this agreement with each other?
  • We can use our imagination and perception to create an authentic agreement that can be honored by everyone because it was formed by everyone.

Before closing the deal, check on the strength of the agreement. People may mumble that they agree when, in fact, there is still something standing in the way of their being “all in.” If the phrase “I’ll try” shows up anywhere in the conversation, there is no real agreement. Trying suggests that there is doubt, disagreement with the overall direction, and a remnant of unwillingness that puts the agreement at risk of being broken.
Of course, there are still times when even an agreement that seems strong is broken. This is the time to review the agreement in slow motion:

  • What was the actual response to the request?
  • What exactly did they say they were going to do? Was it the same thing you were asking for?
  • Was it a strong agreement with specifics?
  • Is there something that was left hanging? A little loose?

Expectations are hard on the human heart and mind and allow us to shift blame to anyone else but ourselves. Agreements offer us the opportunity to co-author the path by which we move life along in more effective and generous ways and enhance our self esteem by the simple act of taking personal responsibility for our yes’s and no’s. Agreements tap into the creative process, honor the relationships we have at work and at home, rescue us from the disappointment of failed expectations, and save the time often spent in places like an idling car on a gray winter day staring out the window wondering what went wrong.

Pushing the Wild Frontier

Carla J. Rotering, MD, M.A. on June 6, 2016

When I was a youngster my parents would often tell me “Don’t get too big for your britches.” Indeed, my entire tiny village on the prairie would announce it regularly, accompanied by clicks of the tongue and a practiced scoff.