Physicians often dramatically change patients’ lives by creating unwanted medical uncertainty and unintentional ambiguity, because how messages are delivered and received depends on preset expectations.
They got the call just after midnight.
Halfway across the country, their adult son had been ejected from a moving vehicle at high speed and was being transferred to the regional trauma center with a head injury and multiple fractures. He already was intubated, chemically paralyzed and sedated. Immediately, their world had become uncertain, and the early messages being received were full of ambiguous commentary. Their sense that normalcy was no longer apparent.
As physicians, regardless of our chosen discipline, we frequently embroil ourselves in our patients’ lives as they learn about fresh medical uncertainty arriving unwanted. We often are the ones delivering these messages. And, unfortunately, all too often in our busyness, we occasionally forget just how deep an impact we create on people’s lives — especially if we have not considered their immediate sense of uncertainty and how our own unintended delivery of ambiguous messages may contribute to it.
We need to be ever mindful that we all — patients and physicians — often carry preset expectations for how these interactions will occur when delivering or receiving difficult messages.
The public media representation on health care delivery practices, and the stereotypes portrayed, can be a disservice to our industry at times. All too frequently, the harshness of human behavior is highlighted in both patients and care providers. Occasionally, however, the genuineness of how clinical providers interact with patients and families is more accurately rendered. These portrayals beautifully demonstrate the empathy and altruism that drive so many of us — and they also can give us personal reassurance that we are indeed privileged to be in an honorable profession.
That these portrayals also make for good “production” further emphasizes how we as humans are inherently drawn to emotionally charged situations. It is built within us all to react with genuine emotion to the complex situations of others, and for how we might help others caught in those situations. Physicians, in particular, do this well, but so do most other health care providers.
These stereotypes are but one example of how our preset expectations arise — for patients and for care providers. Others come from our parents, our families, our culture, our readings and our peers.
Health Care Is Uncertain and Ambiguous
Our industry continues to remain complex, and it will be for generations to come. At its essence, U.S. health care is still a free-market economy. There are numerous sectors inside the industry, including federal and state governments that create influence of varying degree. As each sector attempts to assert its importance, pressure is exerted on the industry that may or may not have demonstrable impact. This ongoing plethora of influences is considered a positive element for any type of free market.
This plethora, however, also creates a routine, constant element of uncertainty and ambiguity for those involved in the industry.
As physicians, we have expectations for our careers, and how we choose to manage them often will determine our satisfaction. Uncertainty and ambiguity are unwanted.
How so? Specifically, the difficulty comes in trying to decide how or when to predict which influence (or set of influences) will create the most significant impact(s) that should be followed as an established trend that ultimately improves (or harms) industry practices.
Physicians have been focused primarily on the quickly changing trends in clinical care for several decades. We all know the rapid dissemination of medical knowledge is difficult to keep pace with, and evolving technologies make this even more complicated. Which trends in clinical care, in addition to measurement and reporting of clinical outcomes, are most relevant? Often, that’s too difficult an answer to generate. The creep of uncertainty and ambiguity starts even in our cherished clinical arenas.
There are numerous studies demonstrating the dwindling morale within the physician workforce. While most physicians are happy with their career choice, the morale problems come primarily from a host of nonclinical issues and influences. Electronic health records, increased bureaucracy and overhead, dwindling compensation despite increased work hours — the list goes on, each independently and collectively compounding the sense of uncertainty and ambiguity.
The stereotype of what the profession is supposed to deliver for physicians and their lifestyles continues to change routinely. Our expectations, therefore, also must change routinely. And we all know changing expectations — after so many years of education, training and practice development — can be exceedingly difficult. However, there is some evidence out there we are indeed changing, albeit gradually. One example is the trend toward employment.
Is DiSC an Influence?
Inherently, most physicians do not enjoy uncertainty and ambiguity. Yes, we are human, but physicians also develop certain attributes that can make accepting change even more difficult. Learning about these can help each of us deal with change better.
For a few years now, our association has been using a number of psychometric tools in our professional development and career support services areas. Psychometric profile development can be useful in several ways, and I routinely encourage people to embrace what they represent.
One tool, among many used by AAPL — the DiSC profile — is used by our faculty and staff fairly often. We now have a few thousand profiles collated, and interesting trends can be drawn that are relevant to this discussion.
Overall, physicians tend to be quite high in the controlling characteristics related to dominance and also fairly high in those related to conscientiousness — so much so, that I have coined a term: We tend to be a bunch of “conscientious dominators” in our professional and daily lives.
Together, these two attributes alone make us want to be in control, and to control the details, of the situations within our environments. That’s not an easy task in this day and age.
As you look at the listed attributes and behaviors of the DiSC tool, you might be better able to resonate with why our industry’s uncertainty and ambiguity are so unsettling at times.
Understanding not only our pre-set expectations for situations, but also our anticipated behaviors as people, often can provide personal insights, as well as a degree of relief, on why we feel uncomfortable with our profession’s changing place in the industry.
Interestingly, we tend to have far less orientation toward steadiness and influence — perhaps surprising, given our caring, empathetic core beliefs and behaviors.
Not Just Another Head Injury
Indeed, as the parents arrived at the bedside of their stricken son, it quickly became apparent to them that normalcy for their family was gone forever. The caring, kind, compassionate physicians and nurses were unable to penetrate the obvious grief of these parents easily. The more effort taken with communicating accurate descriptions of injuries, treatments and prognoses, the higher their grief seemed to escalate, worsening the confusion.
Eventually, as the story unfolded, it became apparent the parents had significant health literacy problems despite a strong command of the English language. Both were naturalized citizens working hard to raise their family and to help advance the next generation. The outpouring of medical language, despite deep levels of caring, overwhelmed the capability of these parents to stay ahead of the situation, and their uncertainty led to an overwhelming feeling of ambiguity (and sense of guilt) for decisions needed with their son.
Decisions to terminate life support and proceed with organ donation are never made readily by any family. And they’re certainly not ones to pursue with any degree of uncertainty or ambiguity.
As physicians, we must continually seek out the uncertainty in our patients’ situations and be certain for ourselves that we have not been contributing — directly or indirectly — to any ambiguity that might have crept into their situations. Personal insight and increased awareness are essential steps for achieving improved leadership — not only for those we influence, but additionally for ourselves as humans.
I encourage all of us to continue seeking deeper levels of understanding for ourselves. As physician leaders, let us get more engaged, stay engaged and help others to become engaged. Creating a broader level of positive change in health care — and society — is within our reach. Proactively helping others to better manage their transitions is a critical component of our professional responsibility — in fact, it has been a professional responsibility since our beginnings.