Heroes Don’t Have to be Talented

A 68 year old man comes into the clinic for a late afternoon appointment. As is typical for him, he’s complaining of vague symptoms that seem like nothing more than those of an older man who doesn’t take great care of himself feeling the effects of…well…not taking great care of himself.

The resident responsible for his care goes through the history and checks a blood pressure in the man’s right arm.

152/103. High. Just like last time.

Then, the resident moves to check it in the other arm because his favorite med school professor hammered home the need to ‘‘always check a blood pressure in both arms. That’s just good medicine.”

This resident swore to himself he was going to be the doctor who does it right. So, for this patient, and all his patients, he moves the cuff to the other side and takes the extra 45 seconds to check the left arm.

It reads 107/73.

90 min. Later, the patient is on the operating table as the vascular surgeon repairs his aortic dissection. 4 hours later, he’s still alive.

The resident ends up a hero, albeit an atypical one.

As Atul Gawande explains in The Heroism of Incremental Care, the physicians who plod through medicine’s sometimes dry but often invaluable fundamentals end up overlooked and undervalued.

The talented and the gifted – those who save lives with unwavering ease and composure– have their legacies etched into medical history and their portraits hung in hospital halls.  The world renowned trauma surgeon who pulls a child back from the verge of death with other-worldly dexterity. The brilliant diagnostician who keeps a family from losing its mother 45 years too early by identifying a life-threatening disease from the tiniest nuance in her lab work.

Heroism, by these standards, jolts into existence as a product of rare and unique abilities.

What would happen if we saw heroism not only as buzzer-beater brilliance, but also as the snowballing impact of choosing to make a difference when no one else will?

Opportunities for heroism would still arise when lives flicker between persisting on and becoming a memory. They would also grow out of all the seemingly minor moments when patients give us the opportunity to understand their joys and sufferings.

Who would the heroes be?

In an era of medicine when we face less time with patients than ever before, the title wouldn’t be limited to the talented, the gifted, or the brilliant. Instead, it would also go to those who practice the most basic and pure crafts in medicine- noticing, listening, and bearing witness. The ones who work in the space of trust and compassion that serves as the foundation for the art and science of medicine. The ones who step up to the bedside and into their patient’s realities.

Yes, the trauma surgeon and the brilliant diagnostician, but also the ones with the patience to always ask, “what else?” The ones who check a blood pressure in both arms, and listen to everyone’s heart and lungs because the touch of caring hands can be a medicine in and of itself.

Even though it may not save a life that time, and even though it’s the 15th time you did it that day, it’s the first time for that patient and it just may be the moment that matters most.

In other words, “Hero” would go to those who choose to make people feel how much they care.

Unlearning Certainty

The first two years of medical school come down to identifying an answer. The answer.

It’s always nestled among five choices, at the bottom of  a carefully constructed paragraph that includes all the information and buzz words we need.

Being a great first or second year student becomes of game of plodding through the cycle of memorization and regurgitation. We learn to see medicine as a series of singular issues that require nothing more than facts and textbooks, and come to believe that pure intellect will let us plow through patient problems with accuracy and efficiency.

Fortunately, medicine is an intricate, ongoing dance between science and compassion, in which we must not only memorize, diagnose, and treat, but also listen, connect and unpack. 

Clinical care that brings patients and physicians together does not stem solely from narrowing down answer choices and recognizing patient presentation patterns. It also unfolds out of recognizing the limitations of certainty and the importance human-to-human trust in healing the body and the soul.

We all have the choice to stop playing the game of certainty. To do less fact regurgitation and more patient engagement. If we do that, we might get a little closer to being the kind of doctor we thought we would be when we first got our crisp, overly starched white coats.

One who refuses to stop at being right and instead, also focuses on doing right. One who constantly circles back to the uncomfortable questions of “Am I sure about this?”,  “What am I missing?”, and “Are we meeting your priorities in your treatment?”

Once we hit the requisite threshold of facts, making the move from good to great depends less on what we know, and more on how often we choose to show up with the presence, attention and humility that keeps us forever curious.

What’s It For

Throughout medical school, we jump to “How’d I do?”

After all, feedback, grades, and evaluations are the engine of success for medical students. But, the answer to “How’d I do?” depends on another, more important question.

“What’s it for?”

When we skip that question, the one that defines the meaning and purpose of anything we do, we end up enrolling in a very specific rubric based on a set values that may or may not align with our own.

For students, every aspect of the curriculum comes with a finely tuned, bullet point list of precise objectives.

What if you’re not doing it for that?

What if you didn’t go to that patient’s room just to remove a few stitches, but also to give them an ear and a chance to feel valued and cared for? How do you define a job well done in that case? 

What if you aren’t in the radiology small group to answer every question right, but instead, are there to help your anxious friend build the confidence to read a chest x-ray in front of his peers.

It doesn’t matter if it’s not on the rubric. It can be on your rubric.

It can be a chance to bring more meaning, humanity, and personal touch to the lives of the patients and peers who share this path with us.

A chance to show up for someone, connect, and uphold the reasons we all come to medicine in the first place. To make a difference.

How’d you do?

I don’t know. That’s up to you now.

Ollie Ollie Oxen Free

The happy hour, the concert, the potluck dinner, or even the phone call to someone we love is a waste of time.

The tests and research projects, they’re more important, right? After all, medical students are busy.

Is that the whole story? Or are we choosing to hide?

Hiding is so appealing because the alternative, stepping out from behind to-do lists, study schedules, and all our plans to get to the next level, makes your authentic, true self  visible.

When you strip away the impressive sounding obligations, people see all of you. Not just the parts you want them to see, or the parts that you construct to be the person you’re supposed to be according to that faculty member, that gatekeeper, or that other person you’re trying to impress.

They might see the neurotic, anxious medical student who has no idea what murmur they’re listening to. Or the one who’s insecure about always changing the answer to “what kind of doctor are you going to be?”

Underneath all of this is the fear of everyone seeing that we’re actually faking it. That we’re not as pristine as the costume we put on.

But isn’t that all of us? Don’t we all feel like an impostor just waiting to get found out?

As we try to gingerly navigate criticism, superhuman expectations, and the tension between who we are and who we think we ought to be, we have two options.

  1. We can frantically try to bury reality underneath a perfectly manicured top coat of competence.
  2. We can let it collect into a pile, proudly stand on top of it and say, “Hey! you see all this? This is all me. Tell me about you.”

One is safe, and easy, and the way it’s always been done. It’s also a clear path to feeling the way you’ve always felt. Disconnected and a little alone, shouldering the ever growing weight of hiding behind a constructed image.

The other is risky and takes guts. With that comes the potential to create connection, community and that wonderful realization that we’re all in this together.

Ollie Ollie Oxen Free. You can come out now. We [want to] see you.

Polarity Thinking in Medical Education


Co-Authored with Dr. Margaret Cary, a physician leadership coach and author of the upcoming book, The Anatomy of a Good Doctor.

This post was originally published on the Arnold P. Gold Foundation Website and The Doctor Weighs In

Medicine thrives on ‘Either/Or’ problem solving. We make a diagnosis. Or we don’t. We prescribe a medication. Or we don’t. Patients are adherent. Or they’re not.

But ‘Either/Or’ thinking isn’t effective for us in leveraging patient safety AND staff satisfaction or combining technological advancement without losing humanistic medical care.

Consider what ‘Either/Or’ thinking means for Jim (not his real name), a patient Dr. Danielle Ofri described to me (Margaret) during our interview for my new book, The Anatomy of a Good Doctor. Jim needed diuretics and, as a New Yorker, spent his days outside his home, running errands. Imagine you’re in a New York subway stairwell. Close your eyes for a minute and inhale deeply…no bathrooms. Jim’s biggest worry was not taking the medicine at the prescribed times, but the thought that he’d have nowhere to pee.

We need ‘Either/Or’ AND ‘Both/And’ thinking in medicine. We take comfort with ‘Either/Or’, our primary method for making decisions and creating differential diagnoses. It’s useful for solving problems—easy problems. For wicked problems,Barry Johnson and his colleagues at Polarity Partnerships have developed Polarity Thinking to leverage ‘Both/And’ tensions. Bonnie Wesorick pioneered Polarity Thinking in healthcare.

Polarity thinking

Polarities are interdependent values that leaders and organizations must balance to catalyze progress, facilitate positive patient outcomes, and avoid an endless cycle of too much of this, then too much of that, then too much of this: Think Goldilocks and the Three Bears, never getting it “just right.”

Imagine a generation of physicians like Danielle Ofri, who worked with Jim on finding a convenient time for him to take his diuretic so he wouldn’t be caught with a full bladder and nowhere to go. They could use their knowledge of Polarities to understand the complexities of healthcare.

The growth of these physicians begins in medical education. Integrating Polarity Thinking into medical school curricula will help them recognize complex dilemmas and maximize their educational experience.

As I (Jack) prepare to enter my third-year clinical rotations, I ask,

How do we students address the tension between excelling under the standards of traditional medical education while also assimilating the transformative lessons in providing engaged, compassionate care to our patients?

Brilliance lies just beyond this question, in seeing traditional medical education and compassionate patient care as Polarities to leverage.

We need both traditional and transformative medical education

Without traditional medical education, students fail to learn the science behind diagnosis and treatment. Without transformative medical education, students fail to develop the skills to create enriching, empathic patient relationships.

The Polarity Map® is depicted in this model:

MedEd Polarity Map Screen Shot from Cary post (600 x 425)Screenshot from http://www.gold-foundation.org/wp-content/uploads/2016/07/MedEdPolarityMap_Complete2.pdf

When we leverage the upside benefits of the two poles, we create a virtuous cycle, bringing each of us closer to the greater purpose of becoming a competent, compassionate physician. Likewise, when we let one pole dominate at the expense of the other, we create a vicious cycle, depriving our patients of the care they deserve and ourselves of the engaged environment that optimizes our education.

Leveraging the tension

What can we do to leverage the tension and move towards the greater purpose? One idea is to create a Polarity Map® and Five-Step S.M.A.L.L. process:

  1. Seeing: what are the two interdependent poles we must leverage?
  2. Mapping: What are the upsides and downsides each pole provides?
    • What is the greater purpose we move toward when we balance these poles?
    • What is the fear of what will happen if we have if we fail to attain leverage?Assessing:
  3. How well or how poorly are we leveraging this Polarity?
  4. Learning: What have we learned from this assessment?
  5. Leveraging: What are the Action Steps we can take to reap the benefits of each pole? What are the Warning Signs that indicate one pole is dominating over the other?

This map shows each pole’s utility and the action steps conducive to success. We walk away with a path to navigate the poles over time.

Medical school is a steep hill to climb. Poorly leveraging Polarities can send us down a slippery slope into burnout, disengagement, and frustration. By recognizing the warning signs of too much focus on one pole, we can adjust our behavior to move into the upside of the other pole.

As with learning to drive a car, our focus here is on course correction.

In our work, Jack as a medical student and Margaret as a leadership coach for physicians, the most valuable part of Polarity mapping is learning to accept the absence of a “check-the-box” solution. We, medical students and physicians, love checking items off lists, knowing we found the correct answer, the solution to a problem. We cannot “check off” ongoing and unsolvable Polarities. We can leverage them to create virtuous cycles of movement from one pole to the other, striving to stay in the upside of both, and minimizing our time in each’s downside.

Once we learn Polarity Thinking, we see Polarities everywhere. Sometimes in our enthusiasm, we may forget the importance of ‘Either/Or’ thinking in healthcare—’Either/Or’ AND ‘Both/And’ are two poles to leverage. Having the tools to see the world through a Polarity Thinking lens adds the capability to leverage complex, permanent dilemmas to our ability to diagnose and treat. Sustainable, continuous progress is no longer a pipe dream. It’s a reality.

Jack said,

“As I walked through this with my study partner, I felt a huge relief wash over me. I realized it’s possible to leverage the two poles (traditional AND transformative education) to attain maximum benefit from both, and to reduce the chances of being pulled toward a one-pole ‘solution’—a ‘fix’ that fails.”

As we think about this, we have reframed our definition of success. Success is no longer about fixing everything, about one right outcome. In Polarity Thinking, success comes from doing, reflecting. and course correcting. The stress from looking for the sole solution we will never find vanishes. More adaptable, progressive, compassionate physicians and leaders emerge, working with our patients to honor their concerns, finding ways to get their care “just right.”