Physicians lack harmony in this age of health reform

At every turn, we in health care are being told we must fundamentally change the way we deliver care to the patients who come to us for assistance, advice, and decisions as to how they can, if not maintain health, at least survive in an increasingly burdensome world.  Whether referenced as medical home, health care home, advanced primary care, patient-centered approaches, or accountable care organizations, it all sounds the same when you look under the hood—CHANGE is expected and is needed, so get with it.

While there is much to say for the value of the redesign, and the development of new principles and structures for delivering care, inherent in all the discussion is an appreciation of the need for many to address their past beliefs, values, and behaviors in creating this new design.

As a Baby Boomer physician (often referred to as “classic” inferring I’m over 55 years of age), it often times feels like an attack on much of what I was trained on that made me  “special” as a practicing physician in my formative years.  But I’m mindful that many others in the world have not been allowed to hold onto past values and have seen their previous valued careers and training fade into an ill-defined, foggy haze.

I’ve continued to appreciate the complexity of what we’re asking of ourselves and others as I expand my understanding of the elements of human behavior.   Through a bevy of authors such as Ariely, Thaler, Sustein, Lehrer, and Gawande, I’ve been made aware of a wealth of scientific information which doesn’t show up in many of our evidence-based medicine principles, but will play a critical role in our efforts to support evidence-based practices.

While we’ve focused in the past century on the value of deductive reasoning, dissecting the whole to understand the component parts, it’s becoming clear that we’re transitioning to an understanding that in reality we live in an organic, adaptive environment. While intellect is of value, it is the baser instincts, the intuitive aspects of our social being that will be a major driver or barrier in any success we’ll achieve in the future.

I’ve often said “the more I learn, the less I know” and have thought it a glib, but honest assessment of how the world looked to me.  But despite the increasing intellectual discomfort, I continue to seek new sources of information which may help me better understand how we can address the challenge of changing behaviors as we face transforming health care.

So because it was on the best seller list, I started reading The Social Animal by David Brooks.  There’s a lot there, and while much of it seems “too clever” as he addresses the lives of Harold and Erica (you’ll have to read it to understand that reference) the book is infused with an incredible number of references and interpretations of concepts previously presented by the august authors I mentioned earlier.

But of course, as I was comfortably revisiting the concepts with which I was already familiar, he had to go and talk about our innate human need for “limerence.”  And it was off I go again, becoming more aware but less comfortable that I understood enough about behavior to be effective in my work.

Limerence refers to the moment when the inner and outer patterns of our life mesh, and we’re in harmony.  Life has a rhythm, usually recurring, moving from difficulty to harmony, difficulty to harmony, in a cycle which often times is a driver for our view on the world.

As I read this, it addresses the inner patterns of our mind, which are established by the experience of life, starting from our very earliest in utero connections with the world awaiting us.  Our memories of our home town, our tendency to become dentists if we’re named Dennis or Denise, the propensity of people named George to move to Georgia, the pleasure I get when I beat the contestant on Wheel of Fortune to the correct puzzle answer, are all part of that inner pattern from which we view the world confronting us.

If that’s the case, and I believe it may very well be, I have rich, vivid, and deeply imprinted views and values based on the patterns drummed into my subconscious by years of medical school and residency.  And I’m not talking about just the memorization of the Krebs Cycle, the nerve dissections in anatomy, but the subconscious values being laid as synaptic tracks across the white and grey matter of my brain.

Those are some deeply imprinted values, some heavily imbedded behaviors, with connections laid down approximating busily travelled freeways traversing my cortex.

So Mr. Brooks, now you’ve got me thinking about another challenge for us–physicians, nurses, pharmacists, and all health care providers.  Today in health care, there certainly is a tension between those inner patterns many of us have, and the external patterns we’re seeing develop in our professional and personal lives.

As we address the technical aspects of medical home, consider the similarities between an ACO and a unicorn (we can all seemingly describe one, but haven’t seen many in our lives), as humans we’ll all consciously and unconsciously be seeking limerence—that place of harmony where we’re in sync both internally and externally with the world.  For it would seem to me that those frequently travelled pathways which forge my unconscious responses present a real challenge to the rapidly changing demands and expectations of the external world we face.

How and when will some of those deeply imbedded patterns be rerouted, reconnected?  What will need to be addressed in the minds of our patients—who while not understanding or appreciating the underlying neurophysiology, are all seeking limerence also.   I’m feeling very “unlimerent” at this moment.  I sense a moment of difficulty in my life.  Can you help me find that harmony now missing?  For you see, I seek limerence, and that’s a  human attribute all of us as “social animals” have—is that a challenge or an opportunity?

Gary Oftedahl is Chief Knowledge Officer of the Institute for Clinical Systems Improvement.

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