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.