Advanced Hindsight
While visiting Duke University Medical Center, one of our Comfort Talk® training sites in MRI, I had the pleasure of meeting Dr. Dan Ariely. He is the James B. Duke Professor of Psychology and Behavioral Economics at Duke University and author of the New York Times bestseller “Predictably Irrational” (1). It is a terrific book evaluating the choices we make in daily life, from picking which beer to drink, to whom we like to go out with, or what we buy, with implications easily exploitable by marketing strategies. And the choices often are not rational – at least not from an objective point of view or awareness. Just coming to his lab tells the visitor one is in for a treat at the “Center for Advanced Hindsight” (isn’t that what all economics departments should be called?)
I became most fascinated by Dr. Ariely’s work through the beginnings he describes in his book. He sustained severe burns as a youth and had to make the odyssey through multiple treatments, surgeries, and dressing changes in the burn unit. The latter is considered as some of the most potentially painful interactions in medicine. The fact that they occur iteratively makes it even harder if one bad experience shapes the expectations ad fears for the next upcoming one.
As a patient, and later as a researcher, he wondered what the rationale – or ideally scientific evidence – was for nursing to rip off the dressings fast rather than removing them slowly from the edges. The slower action seemed to him to be less painful overall which he later demonstrated in experiments. However, he could not convince the nursing staff to change behavior, although they appeared to be mostly very caring individuals.
There was a clash of belief systems where patients’ and healthcare professionals’ assessments of the situation differed. Even when he showed the evidence to the contrary of the current practice, behavior on the unit didn’t change. Finally, he took one of his trusted nurses aside. She admitted that “their understanding had been lacking and that they should change their methods,” but also that “a discussion of the pain inflicted in the bath treatment should take into account the psychological pain the nurses experienced when their patients screamed in agony.” From this point of view, the fast and — for the patient — more agonizing dressing removal was shortening the nurses’ own torment.
As we frequently find, irrational behavior often has an entirely rational explanation as in Ariely’s nursing example. Bob Kegan and Lisa Laskow Lahey, who wrote: “Immunity to Change” (2), emphasize “competing commitments” that often prevent us from doing what we want to do. In the burn unit case one could assume avoidance of one’s own torment as a competing commitment to providing excellent and caring patient treatment. Unless, in that case, one finds a solution to the assumption that a slow dressing removal cannot be executed without inducing extra stress for oneself as the provider, such behavior will never change. To overcome the limitations the assumption imposes, the solution is to observe this assumption at work and design small, safe, and actionable experiments to test whether it is correct or not. I liken it to detoxifying the assumption.
We always include an exercise in assumptions made about resistance to changes in medical care when we train teams in Comfort Talk. Because changes in belief systems cannot be forced, they have to be allowed to develop in the conscience of the provider – and then they will flourish and provide the extra level of comfort needed to embark on patient-centered care while feeling good about oneself.
References
- Ariely D. Predicatably irrational. The hidden forces that shape our decisions. New York: Harper Perennial; 2008. 1-349 p.
- Kegan R, Laskow Lahey L. Immunity to change. Boston: Harvard Business Press; add date; p #.